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* 1. Please indicate if you have ever used any of the following services:

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* 2. Do you currently need help or have help with the following activities:

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* 3. In the next five to ten years do you anticipate needing help with the following activities?

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* 4. If you need assistance where do you go for help?

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* 5. What positive things is your community doing for the older adult population?

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* 6. What else could/should your community be doing to better meet the needs of the older adult population?

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* 7. Have you heard of Jayhawk Area Agency on Aging before?

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* 8. As a Kansas Older Adult, which of the following needs are of concern to you or a likely to be of a concern?

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* 9. What is your Age range?

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* 10. To which gender identity do you most identify?

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* 11. Marital status:

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* 12. Employment status (please mark all that apply):

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* 13. Race (please mark all that apply):

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* 14. Are you of Hispanic or Latino ethnicity?

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* 15. Do you reside within your town’s city limits?

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* 16. Zip code:

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* 17. +4(optional)

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* 18. What is your household’s monthly gross income?

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* 19. How many people are in your household? (Include yourself, your spouse, and any dependents who may be claimed on tax returns)

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