AgeLinc Needs Assessment

Demographic Data

Please answer the following questions about yourself so that we can identify the categories of people responding to our survey.

Question Title

* 1. What is your age?

18 to 34

35 to 54

55 to 64

65 to 74

75 to 84

Over 85

Question Title

* 2. Do you live alone?

Yes

Would rather not say.

Question Title

* 3. Which category BEST describes you? (Please select one)

Older Adult

Caregiver or family member

Business Professional/ For-profit

Government official or employee

Faith-based organization or religious community

Social service agency or other non-profit organization

Other

Question Title

* 4. Which category best describes your race?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

Question Title

* 5. Which category best describes your gender?

Female

Male

Other

Question Title

* 6. What county do you live in?

Cass

Christian

Greene

Jersey

Logan

Macoupin

Mason

Menard

Montgomery

Morgan

Sangamon

Scott

Question Title

* 7. Is English your first language?

Yes

I do not wish to answer