Survey for Service Needs in Muskegon, Oceana and Ottawa Counties

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* 1. Check all that apply.  I am a/an:

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* 2. Please indicate your county of residence

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* 3. Your current living situation :

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* 4. Do you intend to continue living in your current home for the next 5 to 10 years?

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* 5. Do you plan to make any modifications to your home to help you age in place?

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* 6. Can you afford to make home the modification necessary to remain in your home?

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

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* 8. In general, how often do you go online to access the Internet for things like sending or receiving email, getting news and information, paying bills or managing finances or buying products or services?

This includes access from home, work, a mobile device (such as a smart phone), or someplace else.

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* 9. Would you be interested in using a web-based system to video chat with friends and family?

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* 10. How important do you think it is for seniors to have access to adult day services - community based supervised care for older adults?

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* 11. How important do you think it is for seniors to have access to affordable housing?

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* 12. How important do you think it is for seniors to have access to caregiver trainings and support groups?

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* 13. How important do you think it is for seniors to have access to congregate meals - meals offered at community locations?

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* 14. How important do you think it is for seniors to have access to fitness activities specifically geared to older adults?

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* 15. How important do you think it is for seniors to have access to health and wellness programs such as classes in areas of nutrition, chronic disease management, weight control, balance, etc.?

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* 16. How important do you think it is for seniors to have access to home care services like in-home respite, personal care and housekeeping?

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* 17. How important do you think it is for seniors to have access to home delivered meals - nutritious meals delivered to a homebound seniors home?

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* 18. How important do you think it is for seniors to have access to home repair services - help with minor home repair?

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* 19. How important do you think it is for seniors to have access to life enrichment activities such as art, travel and educational opportunities?

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* 20. How important do you think it is for seniors to have access to seasonal services - lawn maintenance or snow removal?

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* 21. How important do you think it is for seniors to have access to service navigation - services that fund seniors to find and access health and supportive services?

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* 22. How important do you think it is for seniors to have access to telephone or home visiting for older adults?

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* 23. How important do you think it is for seniors to have access to transportation for medical appointments or community involvement?

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* 24. Are you able to go shopping, visit the doctor, run errands or go to other places?

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* 25. If yes,do you

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* 26. About how frequently do you interact with friends, family or neighbors in your community?  This interaction could be by phone, in person, email or social media such as Facebook.

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* 27. What kind of help do you feel you need to remain in your home to age in place?

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* 28. Do you identify as male or female?

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* 29. What is your age?

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* 30. Which race/ethnicity best describes you? (Please choose only one.)

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