(Enter community name)would like your input to help determine service priorities for adults 55 years of age and up in(County Name). This survey will take 10-15 minutes to complete. When you are finished, please return your survey in the postage-paid envelope to (Enter address).We greatly appreciate your time.
Are you at least 55 years old?
____ (1)Yes(Please continue with the survey.)
____ (2)No(Please give the survey to someone in your household who is at least 55 years old. If no one in your household is at least 55 years old, please discontinue the survey)
1.Please rate your overall satisfaction with the following services and activities available to adults 55 years of age and up in (County Name)on a scale of 5 to 1 where 5 means “Very Satisfied” and 1 means “Very Dissatisfied.”If you don’t know, please circle 9.
VeryVery Don't
How satisfied are you with:SatisfiedSatisfiedNeutralDissatisfiedDissatisfiedKnow
(A) Public transportation...... 5...... 4...... 3...... 2...... 1.....9
(B) Public parks and trails ...... 5...... 4...... 3...... 2...... 1.....9
(C) Public and non-profit health clinics...... 5...... 4...... 3...... 2...... 1.....9
(D) Active recreation opportunities
(i.e. fitness, golf, swimming, tennis, etc.)...... 5...... 4...... 3...... 2...... 1.....9
(E)Recreation programs (cards, drawing, dancing)5...... 4...... 3...... 2...... 1.....9
(F)Locations of programs...... 5...... 4...... 3...... 2...... 1.....9
(G)Full-time employment opportunities...... 5...... 4...... 3...... 2...... 1.....9
(H)Part-time employment opportunities...... 5...... 4...... 3...... 2...... 1.....9
(I)Arts and cultural amenities...... 4...... 4...... 3...... 2...... 1.....9
(J)Volunteer opportunities...... 5...... 4...... 3...... 2...... 1.....9
(K)Financial planning programs...... 5...... 4...... 3...... 2...... 1.....9
(L)Rent/utility assistance programs...... 5...... 4...... 3...... 2...... 1.....9
(M)Availability of affordable housing...... 5...... 4...... 3...... 2...... 1.....9
(N)Community/senior center services ...... 5...... 4...... 3...... 2...... 1.....9
(O)Community/senior center hours of operations..5...... 4...... 3...... 2...... 1.....9
(P)Opportunities to meet people your own age...5...... 4...... 3...... 2...... 1.....9
2.Which THREE of the items listed above in Question #1 do you or members of your household who are 55 years of age and upCURRENTLY use or participate in the most often? [Using the letters above in Question #1, please write in the letters below for your 1st, 2nd, and 3rd choices, or circle ‘NONE’.]
______
1st Most 2nd Most 3rd Most NONE
Often Often Often
3.In 10 YEARS FROM NOW, which THREE of the services and activities listed above in Question #1 do you or members of your household who are 55 years of age and upthink they will use or participate in the most often? [Using the letters above in Question #1, please write in the letters below for your 1st, 2nd, and 3rd choices, or circle ‘NONE’.]
______
1st Most 2nd Most 3rd Most NONE
Often Often Often
4.The following are issues that you and members of your household who are 55 years of age and upmay face as you grow older. Using a scale of “5 to “1” where “5” is “Very Concerned” and “1” is “Not at all Concerned” please indicate how concerned you are with each of these issues for yourself and members of your household who are 55 years of age and up. If you don’t know, please circle 9.
Issues that you may be concernedVeryA littleNot at all
with as you grow older:Concerned ConcernedNeutral Concerned Concerned Don’t Know
(A) Feelings of social isolation...... 5...... 4...... 3...... 2...... 1...... 9
(B) Personal health issues...... 5...... 4...... 3...... 2...... 1...... 9
(C) Outliving my financial resources...... 5...... 4...... 3...... 2...... 1...... 9
(D) Losing the ability to drive...... 5...... 4...... 3...... 2...... 1...... 9
(E) Not feeling safe ...... 5...... 4...... 3...... 2...... 1...... 9
(F) Unemployment...... 5...... 4...... 3...... 2...... 1...... 9
(G) High housing costs...... 5...... 4...... 3...... 2...... 1...... 9
(H) Affordability of health care...... 5...... 4...... 3...... 2...... 1...... 9
(I) Health issues of spouse over 55 years of age5...... 4...... 3...... 2...... 1...... 9
(J) Language barriers...... 5...... 4...... 3...... 2...... 1...... 9
(K) Lack of contactwithfamily...... 5...... 4...... 3...... 2...... 1...... 9
(L) Loss of insurance...... 5...... 4...... 3...... 2...... 1...... 9
(M) Losing the ability to be active in current
recreational pursuits...... 5...... 4...... 3...... 2...... 1...... 9
(N) Lack of public transportation...... 5...... 4...... 3...... 2...... 1...... 9
(O) Not having the financial ability to retire...... 5...... 4...... 3...... 2...... 1...... 9
(P) Depression...... 5...... 4...... 3...... 2...... 1...... 9
(Q) Lack of worthwhile volunteer opportunities
to engage in...... 5...... 4...... 3...... 2...... 1...... 9
(R) Inability to continue living in my home or
apartment...... 5...... 4...... 3...... 2...... 1...... 9
(S) Other: ______....5...... 4...... 3...... 2...... 1...... 9
5.Which FOUR of the issues listed in Question #4above are you most concerned with for yourself and members of your household who are 55 years of age and up? [Using the letters above in Question #4, please write in the letters below for your 1st, 2nd, 3rd, and 4th choices, or circle ‘NONE’.]
1st: _____2nd:_____3rd: _____4th: _____NONE
6.Which FOUR of the issues listed in Question #4above are you most concerned for regarding ALL residents 55 years of age and up who live in (County Name). ? [Using the letters above in Question #4, please write in the letters or number below for your 1st, 2nd, 3rd, and 4th choices, or circle ‘NONE’.]
1st: _____2nd:_____3rd: _____4th: _____NONE
7.How knowledgeable do you feel you are regarding public and non-profit services that are available to adults 55 years of age and up?
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______(1)Very knowledgeable
______(2)Somewhat knowledgeable
______(3)Not knowledgeable
______(4)Not sure
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8.Cities and non-profit organizations in (County Name)offer a wide range of indoor community facilities that provide opportunities to socialize, fitness, recreation, health care services, sports, cultural activities, and other services for adults aged 55 years and upin (County Name). Some of these community facilities offer services ONLY to adults 55 years of age and upand some of these community facilities offer services to ALL ages, INCLUDING adults 55 years of age and up.
Which ONE of the following best describes your usage of indoor community facilities operated by cities or non-profit organizations in (County Name)?
______(1)I use indoor community facilities that provide services only to adults 55 years of age and up.
______(2)I use indoor community facilities that provide services to all age groups, including adults 55 years of age and up.
______(3)I use both indoor community facilities that provide services to only adults 55 years of age and up and community facilities that provide services to all ages, including adults 55 years of age and up.
______(4)I do not currently use community facilities operated by cities or non-profits.
9.How important do you think it is for community centers operated by cities or non-profit organizations which provide services to adults ages 55 years of age and upto be open longer hours?
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______(1)Very important
______(2)Somewhat important
______(3)Not important
______(4)Not sure
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10.The following are of travel in (County Name). Please check ALL of the methods you currently use to travel throughout the County.
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______(1)I drive a car or truck
______(2)I take public transportation
______(3)A family member/friend drives me
______(4)Bicycle
______(5)Walking
______(6)Cabs
______(7)Dial–a–Ride
______(8)I do not travel. I am homebound.
______(9)Other: ______
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11.From the list in Question #10 above which TWO of the modesof travel around (County Name)do you use most often?[Using the letters above in Question #10, please write in the letters below for your 1st and 2ndchoices, or circle ‘NONE’.]
______
1st Most Often 2nd Most Often
12.In 10 YEARS FROM NOW, which TWOmethods to travel from the list in Question #10 above do you think you will use the most often to travel around (County Name)? [Using the letters above in Question #10, please write in the letters below for your 1st and 2ndchoices, or circle ‘NONE’.]
______
1st MostOften 2nd MostOften ......
13. Several statements about the future of (County Name)as a place to live for adults 55 years of age and up are listed below. Using a scale of “5 to “1” where “5” is “Strongly Agree” and “1” is “Strongly Disagree” please indicate your level of agreement with the following statements. If you don’t know, please circle 9.
(County Name)Future as a Place to LiveStronglyStrongly
for Adults over 55 and up Should Include:AgreeAgreeNeutralDisagreeDisagreeDon’t Know
(A) A larger regional public transit system offering more frequent service
and better connections to other buses, etc...5...... 4...... 3...... 2...... 1...... 9
(B) More social gathering places...... 5...... 4...... 3...... 2...... 1...... 9
(C) Services to understand medical information..5...... 4...... 3...... 2...... 1...... 9
(D) Community centers serving adults 55 years of age and up
openlonger hours...... 5...... 4...... 3...... 2...... 1...... 9
(E) Improved public transportation ...... 5...... 4...... 3...... 2...... 1...... 9
(F) Increased volunteer opportunities for providing
transportation...... 5...... 4...... 3...... 2...... 1...... 9
(G) Improved health care services...... 5...... 4...... 3...... 2...... 1...... 9
(H) More physical fitness opportunities...... 5...... 4...... 3...... 2...... 1...... 9
(I) Additional walking, biking,and hiking trails...5...... 4...... 3...... 2...... 1...... 9
(J) Additional services to check on seniors living
alone...... 5...... 4...... 3...... 2...... 1...... 9
(K) Improved driver education programs ...... 5...... 4...... 3...... 2...... 1...... 9
(L) Increased mentoring opportunities with
younger generations...... 5...... 4...... 3...... 2...... 1...... 9
(M) Increased emphasis on safety...... 5...... 4...... 3...... 2...... 1...... 9
(N) Emergency programs for those who are
bedridden...... 5...... 4...... 3...... 2...... 1...... 9
(O) Increased opportunities to volunteer...... 5...... 4...... 3...... 2...... 1...... 9
(P) Elimination of language barriers for health
care services...... 5...... 4...... 3...... 2...... 1...... 9
(Q) One stop service centers in neighborhoods..5...... 4...... 3...... 2...... 1...... 9
(R) Reduced pricing for public/non-profit services5...... 4...... 3...... 2...... 1...... 9
(S) Programs to reduce the risk of depression...5...... 4...... 3...... 2...... 1...... 9
(T)Affordable housing...... 5...... 4...... 3...... 2...... 1...... 9
(U)Schools/colleges focused on lifetime learning.5...... 4...... 3...... 2...... 1...... 9
(V) Other: ______....5...... 4...... 3...... 2...... 1...... 9
14.Which FOUR of the statements from the list in Question #13 above do you feel BEST represent YOUR VISION for the FUTURE of (County Name)services to adults 55 years of age and up? [Using the letters above in Question #13, please write in the letters below for your 1st, 2nd, 3rd, and 4th choices, or circle ‘NONE’.]
1st: _____2nd:_____3rd: _____4th: _____NONE
15.From the following list, please check ALL of the reasons why you do not use services for adults 55 years of age and up offered by municipalities and non-profits in (County Name)more often.
____ (1) Lack of transportation____ (9) Costs are too high
____ (2) Senior centers are not open enough____ (10) I use services of other agencies ____ (3) Lack of awareness regarding services ____ (11) Outdoor facilities/trails not offered
____ (4) Lack of awareness regarding facilities____ (12) Indoor facilities not offered
____ (5) Community centers are not open enough____ (13) Health programs are expensive
____ (6) Not enough time____ (14) Language barriers
____ (7) Reputation of services is poor____ (15)Other: ______
____ (8) Health services are of poor quality
16.From the following list, please check ALL the ways you would prefer to provide input to local governments and the (community or agency name). (Please check ALL that apply).
_____ (1)Attend meetings or hearings in person
_____ (2)Via a (community or agency name)or local governmentstaffed information booth at a public event in my neighborhood
_____ (3)E-mail correspondence
_____ (4)Telephone
_____ (5)Social media sites
_____ (6)Letter correspondence
_____ (7)Via (community or agency name)Website
17.Thinking about the time you have lived in (County Name), do you generally think the quality of life for persons 55 years of age and up in (County Name)hasbecome better, stayed the same orbecome worse?
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_____ (1)Better
_____ (2)Same
_____ (3)Worse
_____ (4)Not sure
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18.If an additional $100 were available to fund services for adults 55 years of age and up,how would you allocate the funding? [Please be sure your total adds up to $100.]
$______Improve the public transportation system
$______Improve community/senior centers for social activities
$______Improve facilities and program spaces for recreation, trails, fitness and sports activities
$______Improve health care services
$______Improve financial support (rent and utility assistance, etc.)
$______Improve social services (in-home meals, home visitations, etc.)
$______Other: ______
$ 100TOTAL
19. Please circle the response that best reflects your agreement with the following statement.
I would be willing to pay more taxes to fund transportation services dedicated to people aged 55 years and up, such as Dial-A-Ride.
Strongly AgreeAgree Neutral Disagree Strongly Disagree
DEMOGRAPHICS
20.How many years have you lived in (County Name)?______years
21.Which of the following best describes your age?
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____(1) 55 to 59 years old
____(2) 60 to 64 years old
____(3) 65 to 69 years old
____(4) 70 to 74 years old
____(5) 75 to 79 years old
____(6) 80 to 84 years old
____(7) 85 to 89 years old
____(8) 90 years and up
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22.How many persons living in your household (counting yourself)are:
Under age 10____Ages 25-34____Ages 55-64____
Ages 10-19____Ages 35-44____Ages 65-74____
Ages 20-24____Ages 45-54____Ages 75+____
23. Are you of Hispanic or Latin ancestry?
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____(1) Yes
____(2) No
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24.Which of the following best describes your race? (Check all that apply.)
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____(1) African American/Black
____(2) White
____(3)Native American
____(4) Asian/Pacific Islander
____(5) Other: ______
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25.Would you say your total annual household income is: (Note: This question is optional.)
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____(1) Under $25,000
____(2) $25,000 to $49,999
____(3) $50,000 to $74,999
____(4) $75,000 to $99,999
____(5) $100,000 to $149,999
____(6) $150,000 or more
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26.What is your highest level of education?
____(1)Less than high school____(4)Bachelor’s degree
____(2)High school graduate or equivalent____(5)Graduate work
____(3)Some college/Associates degree
©ETC Institute for the PlanET region – October 7, 2011Page 1
27.Which of the following indicates the level of change in your health over the past two years?
____(1) My health is much better.____(4) My health is worse.
____(2) My health is better.____(5) My health is much worse.
____(3) My health has stayed the same.
28.Please share any additional comments you feel are important to help the community in providing services to adults 55 years of age and up.
______
______
Thank you for your time!
Please Return Your Completed Survey in the Enclosed Postage Paid Envelope Addressed to:
(Enter Agency Name and mailing address)
Your response will remain completely confidential. The address information on the sticker to the right willONLY be used
to help identify areas with special interests.
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