ICOA Needs Assessment Survey

Quality of life includes your satisfaction with many different areas of your life. These areas include your physical and mental health, your environment, relationships, and activities that you do for fun. This section has questions that can help us plan programs and resources to maintain or improve your quality of life.

Very Good

Good

Fair

Poor

Very Poor

Very Good

Good

Fair

Poor

Very Poor

	As often as I want	Not quite as often as I want	Not interested in this
Community events, social clubs, support groups	Community events, social clubs, support groups As often as I want	Community events, social clubs, support groups Not quite as often as I want	Community events, social clubs, support groups Not interested in this
Sporting events	Sporting events As often as I want	Sporting events Not quite as often as I want	Sporting events Not interested in this
Volunteer work	Volunteer work As often as I want	Volunteer work Not quite as often as I want	Volunteer work Not interested in this
Education programs	Education programs As often as I want	Education programs Not quite as often as I want	Education programs Not interested in this
Exercise, fitness, physical activities	Exercise, fitness, physical activities As often as I want	Exercise, fitness, physical activities Not quite as often as I want	Exercise, fitness, physical activities Not interested in this
Family visits or activities	Family visits or activities As often as I want	Family visits or activities Not quite as often as I want	Family visits or activities Not interested in this
Library visits	Library visits As often as I want	Library visits Not quite as often as I want	Library visits Not interested in this
Restaurants, eating out	Restaurants, eating out As often as I want	Restaurants, eating out Not quite as often as I want	Restaurants, eating out Not interested in this
Park or nature visits	Park or nature visits As often as I want	Park or nature visits Not quite as often as I want	Park or nature visits Not interested in this
Religion, worship services	Religion, worship services As often as I want	Religion, worship services Not quite as often as I want	Religion, worship services Not interested in this
Senior center meals and activities	Senior center meals and activities As often as I want	Senior center meals and activities Not quite as often as I want	Senior center meals and activities Not interested in this
Shopping	Shopping As often as I want	Shopping Not quite as often as I want	Shopping Not interested in this

As often as I want

Not quite as often
as I want

Not interested in this

Community events, social clubs, support groups

Community events, social clubs, support groups As often as I want

Community events, social clubs, support groups Not quite as often
as I want

Community events, social clubs, support groups Not interested in this

Sporting events

Sporting events As often as I want

Sporting events Not quite as often
as I want

Sporting events Not interested in this

Volunteer work

Volunteer work As often as I want

Volunteer work Not quite as often
as I want

Volunteer work Not interested in this

Education programs

Education programs As often as I want

Education programs Not quite as often
as I want

Education programs Not interested in this

Exercise, fitness, physical activities

Exercise, fitness, physical activities As often as I want

Exercise, fitness, physical activities Not quite as often
as I want

Exercise, fitness, physical activities Not interested in this

Family visits or activities

Family visits or activities As often as I want

Family visits or activities Not quite as often
as I want

Family visits or activities Not interested in this

Library visits

Library visits As often as I want

Library visits Not quite as often
as I want

Library visits Not interested in this

Restaurants, eating out

Restaurants, eating out As often as I want

Restaurants, eating out Not quite as often
as I want

Restaurants, eating out Not interested in this

Park or nature visits

Park or nature visits As often as I want

Park or nature visits Not quite as often
as I want

Park or nature visits Not interested in this

Religion, worship services

Religion, worship services As often as I want

Religion, worship services Not quite as often
as I want

Religion, worship services Not interested in this

Senior center meals and activities

Senior center meals and activities As often as I want

Senior center meals and activities Not quite as often
as I want

Senior center meals and activities Not interested in this

Shopping

Shopping As often as I want

Shopping Not quite as often
as I want

Shopping Not interested in this

	I am currently able	I am not able, but I have the help I need	I am not able, and I do not have the help I need
Cooking meals	Cooking meals I am currently able	Cooking meals I am not able, but I have the help I need	Cooking meals I am not able, and I do not have the help I need
Cleaning the house	Cleaning the house I am currently able	Cleaning the house I am not able, but I have the help I need	Cleaning the house I am not able, and I do not have the help I need
Home maintenance	Home maintenance I am currently able	Home maintenance I am not able, but I have the help I need	Home maintenance I am not able, and I do not have the help I need
Yard maintenance	Yard maintenance I am currently able	Yard maintenance I am not able, but I have the help I need	Yard maintenance I am not able, and I do not have the help I need
Shopping for necessities	Shopping for necessities I am currently able	Shopping for necessities I am not able, but I have the help I need	Shopping for necessities I am not able, and I do not have the help I need
Transportation to medical appointments	Transportation to medical appointments I am currently able	Transportation to medical appointments I am not able, but I have the help I need	Transportation to medical appointments I am not able, and I do not have the help I need
Finding information about services and supports	Finding information about services and supports I am currently able	Finding information about services and supports I am not able, but I have the help I need	Finding information about services and supports I am not able, and I do not have the help I need
Meet my social needs	Meet my social needs I am currently able	Meet my social needs I am not able, but I have the help I need	Meet my social needs I am not able, and I do not have the help I need
Care for another individual, without hurting my health	Care for another individual, without hurting my health I am currently able	Care for another individual, without hurting my health I am not able, but I have the help I need	Care for another individual, without hurting my health I am not able, and I do not have the help I need
Protect myself from abuse and fraud	Protect myself from abuse and fraud I am currently able	Protect myself from abuse and fraud I am not able, but I have the help I need	Protect myself from abuse and fraud I am not able, and I do not have the help I need
Afford necessities such as groceries, gas, medications, utilities.	Afford necessities such as groceries, gas, medications, utilities. I am currently able	Afford necessities such as groceries, gas, medications, utilities. I am not able, but I have the help I need	Afford necessities such as groceries, gas, medications, utilities. I am not able, and I do not have the help I need
Take care of my chronic health needs like diabetes or heart conditions.	Take care of my chronic health needs like diabetes or heart conditions. I am currently able	Take care of my chronic health needs like diabetes or heart conditions. I am not able, but I have the help I need	Take care of my chronic health needs like diabetes or heart conditions. I am not able, and I do not have the help I need
Use a computer or personal device for health care or support	Use a computer or personal device for health care or support I am currently able	Use a computer or personal device for health care or support I am not able, but I have the help I need	Use a computer or personal device for health care or support I am not able, and I do not have the help I need
Use a computer or personal device for fun or socialization	Use a computer or personal device for fun or socialization I am currently able	Use a computer or personal device for fun or socialization I am not able, but I have the help I need	Use a computer or personal device for fun or socialization I am not able, and I do not have the help I need

I am currently able

I am not able, but I have the help I need

I am not able, and I do not have the help I need

Cooking meals

Cooking meals I am currently able

Cooking meals I am not able, but I have the help I need

Cooking meals I am not able, and I do not have the help I need

Cleaning the house

Cleaning the house I am currently able

Cleaning the house I am not able, but I have the help I need

Cleaning the house I am not able, and I do not have the help I need

Home maintenance

Home maintenance I am currently able

Home maintenance I am not able, but I have the help I need

Home maintenance I am not able, and I do not have the help I need

Yard maintenance

Yard maintenance I am currently able

Yard maintenance I am not able, but I have the help I need

Yard maintenance I am not able, and I do not have the help I need

Shopping for necessities

Shopping for necessities I am currently able

Shopping for necessities I am not able, but I have the help I need

Shopping for necessities I am not able, and I do not have the help I need

Transportation to medical appointments

Transportation to medical appointments I am currently able

Transportation to medical appointments I am not able, but I have the help I need

Transportation to medical appointments I am not able, and I do not have the help I need

Finding information about services and supports

Finding information about services and supports I am currently able

Finding information about services and supports I am not able, but I have the help I need

Finding information about services and supports I am not able, and I do not have the help I need

Meet my social needs

Meet my social needs I am currently able

Meet my social needs I am not able, but I have the help I need

Meet my social needs I am not able, and I do not have the help I need

Care for another individual, without hurting my health

Care for another individual, without hurting my health I am currently able

Care for another individual, without hurting my health I am not able, but I have the help I need

Care for another individual, without hurting my health I am not able, and I do not have the help I need

Protect myself from abuse and fraud

Protect myself from abuse and fraud I am currently able

Protect myself from abuse and fraud I am not able, but I have the help I need

Protect myself from abuse and fraud I am not able, and I do not have the help I need

Afford necessities such as groceries, gas, medications, utilities.

Afford necessities such as groceries, gas, medications, utilities. I am currently able

Afford necessities such as groceries, gas, medications, utilities. I am not able, but I have the help I need

Afford necessities such as groceries, gas, medications, utilities. I am not able, and I do not have the help I need

Take care of my chronic health needs like diabetes or heart conditions.

Take care of my chronic health needs like diabetes or heart conditions. I am currently able

Take care of my chronic health needs like diabetes or heart conditions. I am not able, but I have the help I need

Take care of my chronic health needs like diabetes or heart conditions. I am not able, and I do not have the help I need

Use a computer or personal device for health care or support

Use a computer or personal device for health care or support I am currently able

Use a computer or personal device for health care or support I am not able, but I have the help I need

Use a computer or personal device for health care or support I am not able, and I do not have the help I need

Use a computer or personal device for fun or socialization

Use a computer or personal device for fun or socialization I am currently able

Use a computer or personal device for fun or socialization I am not able, but I have the help I need

Use a computer or personal device for fun or socialization I am not able, and I do not have the help I need

	Very frequently	Frequently	Not often	Never
Crime in your area	Crime in your area Very frequently	Crime in your area Frequently	Crime in your area Not often	Crime in your area Never
Friends or family committing suicide	Friends or family committing suicide Very frequently	Friends or family committing suicide Frequently	Friends or family committing suicide Not often	Friends or family committing suicide Never
Friends or family becoming drug addicted	Friends or family becoming drug addicted Very frequently	Friends or family becoming drug addicted Frequently	Friends or family becoming drug addicted Not often	Friends or family becoming drug addicted Never
Being prepared for a natural disaster	Being prepared for a natural disaster Very frequently	Being prepared for a natural disaster Frequently	Being prepared for a natural disaster Not often	Being prepared for a natural disaster Never
Falling while walking	Falling while walking Very frequently	Falling while walking Frequently	Falling while walking Not often	Falling while walking Never
Living in pain	Living in pain Very frequently	Living in pain Frequently	Living in pain Not often	Living in pain Never
Being lonely	Being lonely Very frequently	Being lonely Frequently	Being lonely Not often	Being lonely Never
Paying my bills	Paying my bills Very frequently	Paying my bills Frequently	Paying my bills Not often	Paying my bills Never
Losing my housing	Losing my housing Very frequently	Losing my housing Frequently	Losing my housing Not often	Losing my housing Never
Bowel or bladder accidents	Bowel or bladder accidents Very frequently	Bowel or bladder accidents Frequently	Bowel or bladder accidents Not often	Bowel or bladder accidents Never
Problems with memory	Problems with memory Very frequently	Problems with memory Frequently	Problems with memory Not often	Problems with memory Never

Very frequently

Frequently

Not often

Never

Crime in your area

Crime in your area Very frequently

Crime in your area Frequently

Crime in your area Not often

Crime in your area Never

Friends or family committing suicide

Friends or family committing suicide Very frequently

Friends or family committing suicide Frequently

Friends or family committing suicide Not often

Friends or family committing suicide Never

Friends or family becoming drug addicted

Friends or family becoming drug addicted Very frequently

Friends or family becoming drug addicted Frequently

Friends or family becoming drug addicted Not often

Friends or family becoming drug addicted Never

Being prepared for a natural disaster

Being prepared for a natural disaster Very frequently

Being prepared for a natural disaster Frequently

Being prepared for a natural disaster Not often

Being prepared for a natural disaster Never

Falling while walking

Falling while walking Very frequently

Falling while walking Frequently

Falling while walking Not often

Falling while walking Never

Living in pain

Living in pain Very frequently

Living in pain Frequently

Living in pain Not often

Living in pain Never

Being lonely

Being lonely Very frequently

Being lonely Frequently

Being lonely Not often

Being lonely Never

Paying my bills

Paying my bills Very frequently

Paying my bills Frequently

Paying my bills Not often

Paying my bills Never

Losing my housing

Losing my housing Very frequently

Losing my housing Frequently

Losing my housing Not often

Losing my housing Never

Bowel or bladder accidents

Bowel or bladder accidents Very frequently

Bowel or bladder accidents Frequently

Bowel or bladder accidents Not often

Bowel or bladder accidents Never

Problems with memory

Problems with memory Very frequently

Problems with memory Frequently

Problems with memory Not often

Problems with memory Never

ICOA Needs Assessment

SECTION 1: Quality of Life

Question Title

* 1. How would you rate your overall quality of life? Please choose one response.

Question Title

* 2. How often are you able to participate in the following? Please choose one response in each row.

Question Title

* 3. Are you able to do the following activities by yourself or with help?
Please pick one in each row

Question Title

* 4. How often do you worry about the following topics

ICOA Needs Assessment

SECTION 1: Quality of Life

Question Title

* 1. How would you rate your overall quality of life? Please choose one response.

Question Title

* 2. How often are you able to participate in the following? Please choose one response in each row.

Question Title

* 3. Are you able to do the following activities by yourself or with help? Please pick one in each row

Question Title

* 4. How often do you worry about the following topics

* 3. Are you able to do the following activities by yourself or with help?
Please pick one in each row