Stanislaus County Older Adult Needs Assessment

Daily Activities

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* 1. For each of the following items, please indicate how difficult it is for you to perform each of the activities without help by choosing the appropriate box on the scale.

	No Difficulty	Minor Difficulty	Serious Difficulty	Unable to Do at All
Eating	Eating No Difficulty	Eating Minor Difficulty	Eating Serious Difficulty	Eating Unable to Do at All
Bathing	Bathing No Difficulty	Bathing Minor Difficulty	Bathing Serious Difficulty	Bathing Unable to Do at All
Dressing/Undressing	Dressing/Undressing No Difficulty	Dressing/Undressing Minor Difficulty	Dressing/Undressing Serious Difficulty	Dressing/Undressing Unable to Do at All
Getting into and out of bed and/or chair	Getting into and out of bed and/or chair No Difficulty	Getting into and out of bed and/or chair Minor Difficulty	Getting into and out of bed and/or chair Serious Difficulty	Getting into and out of bed and/or chair Unable to Do at All
Getting to the bathroom	Getting to the bathroom No Difficulty	Getting to the bathroom Minor Difficulty	Getting to the bathroom Serious Difficulty	Getting to the bathroom Unable to Do at All
Walking	Walking No Difficulty	Walking Minor Difficulty	Walking Serious Difficulty	Walking Unable to Do at All
Preparing meals	Preparing meals No Difficulty	Preparing meals Minor Difficulty	Preparing meals Serious Difficulty	Preparing meals Unable to Do at All
Shopping	Shopping No Difficulty	Shopping Minor Difficulty	Shopping Serious Difficulty	Shopping Unable to Do at All
Managing medication	Managing medication No Difficulty	Managing medication Minor Difficulty	Managing medication Serious Difficulty	Managing medication Unable to Do at All
Managing money	Managing money No Difficulty	Managing money Minor Difficulty	Managing money Serious Difficulty	Managing money Unable to Do at All
Using the telephone	Using the telephone No Difficulty	Using the telephone Minor Difficulty	Using the telephone Serious Difficulty	Using the telephone Unable to Do at All
Doing light housework	Doing light housework No Difficulty	Doing light housework Minor Difficulty	Doing light housework Serious Difficulty	Doing light housework Unable to Do at All
Doing heavy housework	Doing heavy housework No Difficulty	Doing heavy housework Minor Difficulty	Doing heavy housework Serious Difficulty	Doing heavy housework Unable to Do at All

Other (please specify)
If you need assistance, please state who helps you: relative, friend, employee of an agency, IHSS worker, etc.

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* 2. Below is a list of issues, conditions, and concerns that affect quality of life. Consider how much each of them is an issue or problem for you by checking one item on each scale.

	Not a Problem	Minor Problem	Serious Problem	Very Serious Problem	Not Applicable
Feeling safe and secure at home	Feeling safe and secure at home Not a Problem	Feeling safe and secure at home Minor Problem	Feeling safe and secure at home Serious Problem	Feeling safe and secure at home Very Serious Problem	Feeling safe and secure at home Not Applicable
Finding work (full or part-time)	Finding work (full or part-time) Not a Problem	Finding work (full or part-time) Minor Problem	Finding work (full or part-time) Serious Problem	Finding work (full or part-time) Very Serious Problem	Finding work (full or part-time) Not Applicable
Obtaining information about senior services	Obtaining information about senior services Not a Problem	Obtaining information about senior services Minor Problem	Obtaining information about senior services Serious Problem	Obtaining information about senior services Very Serious Problem	Obtaining information about senior services Not Applicable
Receiving services/benefits for older adults	Receiving services/benefits for older adults Not a Problem	Receiving services/benefits for older adults Minor Problem	Receiving services/benefits for older adults Serious Problem	Receiving services/benefits for older adults Very Serious Problem	Receiving services/benefits for older adults Not Applicable
Getting long-term care	Getting long-term care Not a Problem	Getting long-term care Minor Problem	Getting long-term care Serious Problem	Getting long-term care Very Serious Problem	Getting long-term care Not Applicable
Finding affordable housing	Finding affordable housing Not a Problem	Finding affordable housing Minor Problem	Finding affordable housing Serious Problem	Finding affordable housing Very Serious Problem	Finding affordable housing Not Applicable
Remaining in your own home	Remaining in your own home Not a Problem	Remaining in your own home Minor Problem	Remaining in your own home Serious Problem	Remaining in your own home Very Serious Problem	Remaining in your own home Not Applicable
Getting legal assistance	Getting legal assistance Not a Problem	Getting legal assistance Minor Problem	Getting legal assistance Serious Problem	Getting legal assistance Very Serious Problem	Getting legal assistance Not Applicable
Losing your memory	Losing your memory Not a Problem	Losing your memory Minor Problem	Losing your memory Serious Problem	Losing your memory Very Serious Problem	Losing your memory Not Applicable
Poor vision or blindness	Poor vision or blindness Not a Problem	Poor vision or blindness Minor Problem	Poor vision or blindness Serious Problem	Poor vision or blindness Very Serious Problem	Poor vision or blindness Not Applicable
End of life issues	End of life issues Not a Problem	End of life issues Minor Problem	End of life issues Serious Problem	End of life issues Very Serious Problem	End of life issues Not Applicable
Feeling lonely	Feeling lonely Not a Problem	Feeling lonely Minor Problem	Feeling lonely Serious Problem	Feeling lonely Very Serious Problem	Feeling lonely Not Applicable
Feeling sad frequently	Feeling sad frequently Not a Problem	Feeling sad frequently Minor Problem	Feeling sad frequently Serious Problem	Feeling sad frequently Very Serious Problem	Feeling sad frequently Not Applicable
Having enough money to meet expenses	Having enough money to meet expenses Not a Problem	Having enough money to meet expenses Minor Problem	Having enough money to meet expenses Serious Problem	Having enough money to meet expenses Very Serious Problem	Having enough money to meet expenses Not Applicable
Getting enough food	Getting enough food Not a Problem	Getting enough food Minor Problem	Getting enough food Serious Problem	Getting enough food Very Serious Problem	Getting enough food Not Applicable
Transportation	Transportation Not a Problem	Transportation Minor Problem	Transportation Serious Problem	Transportation Very Serious Problem	Transportation Not Applicable
Crime and/or fraud	Crime and/or fraud Not a Problem	Crime and/or fraud Minor Problem	Crime and/or fraud Serious Problem	Crime and/or fraud Very Serious Problem	Crime and/or fraud Not Applicable
Feeling isolated	Feeling isolated Not a Problem	Feeling isolated Minor Problem	Feeling isolated Serious Problem	Feeling isolated Very Serious Problem	Feeling isolated Not Applicable
Accidents in the home (i.e. falling)	Accidents in the home (i.e. falling) Not a Problem	Accidents in the home (i.e. falling) Minor Problem	Accidents in the home (i.e. falling) Serious Problem	Accidents in the home (i.e. falling) Very Serious Problem	Accidents in the home (i.e. falling) Not Applicable
Physical, emotional, or financial abuse	Physical, emotional, or financial abuse Not a Problem	Physical, emotional, or financial abuse Minor Problem	Physical, emotional, or financial abuse Serious Problem	Physical, emotional, or financial abuse Very Serious Problem	Physical, emotional, or financial abuse Not Applicable
Getting relief from caregiving responsibilities	Getting relief from caregiving responsibilities Not a Problem	Getting relief from caregiving responsibilities Minor Problem	Getting relief from caregiving responsibilities Serious Problem	Getting relief from caregiving responsibilities Very Serious Problem	Getting relief from caregiving responsibilities Not Applicable

Other (please specify)
What caregiving services would assist you?

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* 3. Because we are trying to identify the needs of our diverse older adult population, your responses to the following questions are very important to us. If you feel uncomfortable answering a particular question, please skip it. Please do your best in answering all questions by checking one box per question. All responses will be kept confidential.

55-59

60-64

65+

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* 4. Gender

Male

Female

Transgender Female to Male

Transgender Male to Female

Genderqueer/Gender Non-binary

Decline to State

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* 5. Sexual Orientation

Heterosexual

Bisexual

Gay/Lesbian/Same-Gender Loving

Questioning/Unsure

Not Listed

Decline to State

Other (please specify)

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* 6. Sex at birth

Male

Female

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* 7. Do you identify as part of the LGBTQ community?

Yes, Please go to next question

No, Please skip to Q9

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* 8. If you identify as part of the LGBTQ community, do you have access to services and programs appropriate for your needs?

Yes

I don't know

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* 9. What is your 2019 Monthly Income (Check One)

Single - $1,041 or less

Single - $1042-$1,301

Single - $1,302 or more

Two Person - $1,409 or less

Two Person - $1,410-$1,761

Two Person - $1,762 or more

Decline to state

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* 10. Are you a veteran?

Yes

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* 11. Primary Language

English

Spanish

Other (please specify)

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* 12. Do you receive information in your preferred language?

Yes

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* 13. Ethnicity:

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

Multiple Races

Decline to state

Other (please specify)

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* 14. Do you have access to services and/or programs appropriate for your ethnicity?

Yes

I don't know

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* 15. Which town, city or rural area do you live in?

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* 16. Living Arrangement:

Live Alone

Live with children

Live with spouse/significant other

Live with non-relatives

Live with other relatives

Live with paid caregiver

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* 17. Living Quarters/Type of Housing

Single family home

Condo/townhouse/duplex

Apartment

Mobile home/trailer

Boarding house

Assisted living

Hotel

No residence

Other (please specify)

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* 18. During the last year were you in danger of losing your home or place of residence?

Yes

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* 19. If you lost your place of residence, what solution did you find?

Moved in with family/friends.

Moved to Board and Care facility

Do not have a permanent home

Other (please specify)

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* 20. What is your most often used form of transportation?

Personal vehicle

Ride with relatives

Ride with friends

Senior bus

Taxi

Public transportation

Dial-a-Ride

Uber/Lyft

None Available

Walk

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* 21. Is public transportation accessible where you live?

Yes, Please answer Q22.

No, Please skip to Q23.

I don't know

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* 22. Do you use public transportation?

Yes

I do not need it/I have other transportation

I am not physically able to use public transportation

I am not comfortable using public transportation

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* 23. Please state why public transportation is NOT accessible where you live.

None in the area.

Public transportation doesn't run often enough

Too far from my home.

Other (please specify)

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* 24. Do you have plans in case of natural or man-made disasters?

Yes

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* 25. How often do you participate in some form of exercise (any physical activity done for the purpose of improving or maintaining health)?

I do not exercise

Every day

2-3 times per week

Once a week

Occasionally

Other (please specify)

Stanislaus County Older Adult Needs Assessment

Daily Activities

Question Title

* 1. For each of the following items, please indicate how difficult it is for you to perform each of the activities without help by choosing the appropriate box on the scale.

Question Title

* 2. Below is a list of issues, conditions, and concerns that affect quality of life. Consider how much each of them is an issue or problem for you by checking one item on each scale.

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* 4. Gender

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* 5. Sexual Orientation

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* 6. Sex at birth

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* 7. Do you identify as part of the LGBTQ community?

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* 8. If you identify as part of the LGBTQ community, do you have access to services and programs appropriate for your needs?

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* 9. What is your 2019 Monthly Income (Check One)

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* 10. Are you a veteran?

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* 11. Primary Language

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* 12. Do you receive information in your preferred language?

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* 13. Ethnicity:

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* 14. Do you have access to services and/or programs appropriate for your ethnicity?

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* 15. Which town, city or rural area do you live in?

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* 16. Living Arrangement:

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* 17. Living Quarters/Type of Housing

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* 18. During the last year were you in danger of losing your home or place of residence?

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* 19. If you lost your place of residence, what solution did you find?

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* 20. What is your most often used form of transportation?

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* 21. Is public transportation accessible where you live?

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* 22. Do you use public transportation?

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* 23. Please state why public transportation is NOT accessible where you live.

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* 24. Do you have plans in case of natural or man-made disasters?

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* 25. How often do you participate in some form of exercise (any physical activity done for the purpose of improving or maintaining health)?

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* 26. Are there any causes or issues you feel strongly about? Please describe.