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* 1. Q1. Are you a resident of Herkimer County?

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* 2. Q2. What is the name of your municipality or community? For some people, this would mean the town or village in which they live, or it could be their neighborhood. For some people, it could be their subdivision or development.

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* 3. Q3. How long have you lived in your community?

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* 4. How long have you lived in your current residence?

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* 5. How would you rate your current community as a place for people to live as they age?

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* 6. Thinking about your future years, are you more likely to move to a different community, move to a different residence within your current community or stay in your current residence and never move? (CHECK ONLY ONE)

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* 7. Some people find that they need or want to move out of their residence as they get older. If you were to consider moving out of your current residence, would the following be a major factor, minor factor, or not a factor at all in your decision to move?

  Major Factor
Minor Factor
Not a Factor
Not Sure
a. Wanting a smaller size home
b. Wanting a larger size home
c. The cost of maintaining your current residence
d. Wanting a home that will help you live independently as you age, for example a home without stairs

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* 8. Some people find that they need or want to move out of their community, as they get older. If you were to consider moving out of your current community, would the following be a major factor, a minor factor, or not a factor at all in your decision to move?

  Major Factor
Minor Factor
Not a Factor
Not Sure
a. Your personal safety or security concerns….
b. Wanting to move to an area that has better health care facilities
c. Wanting to be closer to family
d. Needing more access to public transportation
e. Wanting to live in a different climate
f. Wanting to live in an area that has a lower cost of living
g. Wanting to live in an area with better opportunities for social interaction

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* 9. How important is it for you to remain in your current community for as long as possible?

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* 10. Which of the following types of homes best describes where you currently live?
(CHECK ONLY ONE)

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* 11. Do you own or rent your primary home, or do you have some other type of living arrangement, like living with a family member or friend?

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* 12. How important is it for you to be able to live independently in your own home as you age?

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* 13. Some people find that they need to make modifications to their residence to enable them to stay there for as long as possible. Does your current residence need any major repairs, modifications, or changes to enable you to stay there for as long as possible?

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* 14. Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent
Very Good
Good
Fair
Poor
Not Sure
a. Home modification and repair contractors who are trustworthy, do quality work, and are affordable
b. A home repair service for low-income and for older adults that help with things like roof or window repairs
c. Seasonal services such as lawn work or snow removal for low-income and older adults

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* 15. Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent
Very Good
Good
Fair
Poor
Not Sure
a. Sidewalks that are in good condition, safe for pedestrians, and accessible for wheelchairs or other assistive mobility devices
b. Well-lit, accessible, safe streets and intersections for all users
c. Audio and visual pedestrian crossings
d. Separate pathways for bicyclists and pedestrians
e. Well-maintained streets
f. Easy to read traffic signs
g. Enforced speed limits
h. Bus Shelters with seating

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* 16. Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent
Very Good
Good
Fair
Poor
Not Sure
a. Well-maintained homes and properties
b. Affordable housing options for adults of low-income levels such as older active adult communities, assisted living and communities with shared facilities and outdoor spaces
c. Well-maintained, safe low-income housing
d. Homes that are built with things like a no-step entrance, wider doorways, and first floor bedrooms and bathrooms
e. Well-maintained parks
f. Safe parks
g. Public buildings and spaces including restrooms that are accessible to people of different physical abilities
h. Enough benches for resting in public areas like parks, along sidewalks, and around public buildings
i. Conveniently located emergency care centers
j. Well-maintained hospitals and health care facilities
k. Neighborhood watch programs
l. Conveniently located public parking lots and areas to park including handicapped parking
m. Affordable public parking

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* 17. How do you usually get around your community for things like shopping, visiting the doctor, running errands, or other things?

  Yes or No
a. Walk
b. Drive yourself
c. Have others drive you
d. Take a taxi
e. Use a ride source company such as Uber or Lyft
f. Use a special transportation service, such as one for seniors or persons with disabilities
g. Use public transportation
h. Ride a bicycle
i. Some other way
j. I do not get out of the house

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* 18. Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent
Very Good
Good
Fair
Poor
Not Sure
a. Accessible and convenient public transportation
b. Affordable public transportation
c. Well-maintained public transportation vehicles
d. Timely public transportation
e. Safe public transportation stops or areas that are accessible to people of varying physical abilities
f. Special transportation services for people with disabilities and older adults

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* 19. Thinking now about health care professionals in your community.

Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent
Very Good
Good
Fair
Poor
Not Sure
a. Availability and well-staffed in-home health care providers
b. Affordable in-home health care providers
c. Availability and well-staffed healthcare providers for nursing homes & assisted living facilities
d. A variety of health care professionals including specialists
e. Health care professionals who speak different languages
f. Respectful and helpful hospital and clinic staff

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* 20. Thinking now about health and wellness services in your community.
Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent, Very Good, Good, Fair, Poor,  or Not Sure
a. Affordable health and wellness programs and classes in areas such as nutrition, smoking cessation, and weight control
b. Affordable fitness activities specifically geared towards older adults
c. Conveniently located health and social services
d. Services that provide people to help seniors easily find and access health and supportive services
e. Emotional and mental health services
f. Affordable home care services including personal care and housekeeping
g. Easily understandable and helpful local hospital or clinic answering services

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* 21. Do you have transportation access to the following services?

  Yes or No
a. Health and wellness programs and classes in areas such as nutrition, smoking cessation, and weight control
b. Fitness activities specifically geared towards older adults
c. Health and social services (i.e. medical appointments)
d. Services that provide people to help seniors easily find and access health and supportive services
e. Emotional and mental health services
f. Home care services including personal care and housekeeping
g. Local hospital or clinic answering services
h. Grocery store or places to obtain food for meals
i. Run errands (i.e. bank, pharmacy, post office, etc.)
j. Places of worship

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* 22. Social Participation, Inclusion and Education Opportunities

How often do you have contact with family, friends, or neighbors who do not live with you?

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* 23. How often do you feel the following?

  Often Sometimes Rarely or Never
a. I lack companionship
b. I feel left out
c. I feel isolated from others
d. In the last 30 days, how often do you feel sad?
e. Thoughts about suicide?

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* 24. Do you have friends or family that can provide assistance to you?

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* 25. Do you use the following sources for continuing education or self-improvement classes or workshops in your community?

  Yes or No
a. Department of Parks and Recreation
b. Faith community
c. Local organizations or businesses
d. Community Center
e. Senior Center
f. Offerings through my work
g. Online Programs
h. Community College
i. Some other source
j. I do NOT participate in any continuing education/self-improvement classes

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* 26. If you chose i. Some other source, please list the source.

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* 27. Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent, Very Good, Fair, Poor or Not Sure
a. Conveniently located entertainment venues
b. Activities geared specifically towards older adults
c. Activities that offer senior discounts
d. Activities that are affordable to all residents
e. Activities that involve both younger and older people
f. A variety of cultural activities for diverse populations
g. Local schools that involve older adults in events and activities
h. Continuing education classes or social clubs to pursue new interests, hobbies or passions
i. Driver education or refresher courses

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* 28. Volunteering and Civic Engagement

Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent, Very Good, Good, Fair, Poor or Not Sure
a. A range of volunteer activities to choose from
b. Volunteer training opportunities to help people perform better in their volunteer roles
c. Opportunities for older adults to participate in decision making bodies such as community councils or communities
d. Easy to find information on available local volunteer opportunities
e. Transportation to and from volunteer activities for those who need it

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* 29. Job Opportunities

Which of the following best describes your current employment status?

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* 30. How likely is it that you will continue to work as long as possible, rather than choosing to retire and no longer work for pay?

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* 31. Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent, Very Good, Good, Fair, Poor, or Not Sure
a. A range of job opportunities for older adults
b. Job training opportunities for older adults who want to learn new job skills within their job or get training in a different field of work
c. Jobs that are adapted to meet the needs of people with disabilities
d. Policies that ensure older adults can continue to have equal opportunity to work for as long as they want or need to regardless of their age

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* 32. Do you work because of a financial necessity?

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* 33. Do you risk losing services if you work? (Examples of services include but are not limited to SNAP benefits, Social Security, etc.)

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* 34. Community Information

Would you turn to the following resources if you, a family member or friend needed information about services for older adults such as caregiving services, home delivered meals, home repair, medical transport, or social activities?

  Yes, No or Not Sure
a. Local Senior Centers
b. Office for the Aging
c. Family or friends
d. Local Non-profit organizations (i.e. Catholic Charities, Resource Center for Independent Living)
e. AARP
f. Faith-based organizations like churches or synagogues
g. Internet
h. Phone book
i. Your doctor or other health care professional
j. Local government offices like the Health Department
k. Library
l. Community College
m. Other

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* 35. If you have chosen m. Other, please list the resource.

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* 36. Would you rate your community as excellent, very good, good, fair, or poor on having the following?

  Excellent, Very Good, Good, Fair, Poor, or Not Sure
a. Access to community information in one central source
b. Clearly displayed printed community information with large lettering
c. Free access to computers and the Internet in public places such as the library, senior centers or government buildings
d. Community information that is delivered in person to people who may have difficulty or may not be able to leave their home
e. Community information that is available in a number of different languages

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* 37. Demographics

D1. Are you male, female or transgender?

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* 38. D2. What is your age as of your last birthday?

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* 39. D3. What is your current marital status?

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* 40. D4. Are you or your spouse or partner currently a member of AARP?

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* 41. D5. Besides you, do you have any of the following people living in your household?

  Yes or No
a. Child or Children under 18
b. Child or Children 18 or older
c. Child or Children away at college
d. Parents
e. Other adult relative or friend 18 or older

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* 42. D6. How many people are in your household?

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* 43. D7. In general, how would you rate your health?

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* 44. D8. Do you have health care insurance coverage on yourself?

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* 45. D9. Does any disability, handicap, or chronic disease keep you or your spouse or partner from participating fully in work, school, housework, or other activities? (CHECK ONLY ONE)

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* 46. D10. A family caregiver is someone who provides care for an adult loved one who is ill, frail, elderly, or has a physical, mental, or emotional disability. This may include helping with personal needs like bathing or dressing, meals, household chores, shopping, transportation, managing medical care or finances, or even visiting regularly to see how they are doing. This adult need not live with you. 

Are you currently a family caregiver providing unpaid care to an adult loved one to help them take care of themselves?

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* 47. D11. How likely is it that you will provide unpaid care to an adult loved one in the future?

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* 48. D12. What is the highest level of education that you completed?

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* 49. D13. Are you of Hispanic, Spanish, or Latino origin or descent?

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* 50. D14. If you are Hispanic or Latino, please indicate which language best represents the language you speak at home?

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* 51. D15. What is your race? (CHECK ALL THAT APPLY)

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* 52. D16. How often do you vote?

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* 53. D17. Do you know how to use the Internet?

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* 54. D18. Do you know how to send e-mail?

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* 55. D19. Which best describes how often you use the Internet?

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* 56. What was your annual household income before taxes in 2020?

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* 57. D21. What is your 5-digit zip code?

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* 58. D22. How would you rate your current community as a place for people to live as they age?

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* 59. Please enter your contact information for the gas card drawing.

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