2009 Needs Assessment for Senior Citizens’ Services



2014 Needs Assessment for Senior Citizens’ Services

You are being invited to participate in an aging survey to identify services which YOU determine are important now and in the next five years. This questionnaire asks a variety of questions about needs and their relationship to you. You are being asked read the questionnaire, complete it, and return it to the address provided.

The results of this survey will assist your Alabama Tombigbee Regional Commission Area Agency on Aging in fulfilling its commitment of service to Alabama’s seniors. NOTE: Your responses will be kept completely confidential, so please encourage others to participate in this very important process. This survey can also be found at . If you have any questions, please call the Area Agency on Aging at 1-888-617-0500.

To begin, we need to know something about you.

1. Which county do you live in? ____________________________________________________

2. In what year were you born? __________

3. What is your gender? Male Female

4. What is your race? (Check only one.)

African American/Black Asian Caucasian/White

Native American Native Hawaiian/Pacific Islander Other __________

5. Are you of Spanish, Latino, or Hispanic origin? Yes No

6. What is your marital status? (Check only one.)

Never Married Separated Divorced Widowed Married

7. What is the highest grade or year you finished in school? (Check only one.)

8th grade or less Some college Some high school

Two-year college degree High school diploma or GED Four-year college degree

Technical school Post graduate degree (masters/doctorate)

8. What is your household monthly income (i.e., net monthly income after taxes)?

Less than $958 $959 - $1,274 $1,275 - $1,436 More than $1,437

9. From which Area Agency on Aging program do you receive services?

Congregate meal at a Senior Center Home delivered meal from a Senior Center

Alabama Cares Medicaid Waiver

None of the above I’m not sure

Next, please tell us which service(s) are Important to you or may be of concern in the next five years. (Place an “X” in the appropriate box.)

10. In regards to services in the home, I think the following services are IMPORTANT or will be important to me in the future (check all that apply):

Assistance in bathing or showering

Assistance in getting dressed

Assistance in preparing meals

Having meals delivered to my home

Assistance with laundry, house work, or yard work

Assistance in caring for my relatives or friends

Transportation to doctors’ offices and shopping

Assistance in paying bills and balancing my checkbook

Assistance with income tax forms

Assistance with legal paperwork

Information on government services

Information on services in town

Having an adult day care center close by in case I

or a family member needs more help during the day

Assistance in planning for retirement

11. In regards to health care, I think the following services are IMPORTANT or will be important to me in the future (check all that apply):

Information on diseases and health problems

Information on health insurance

Information on keeping a healthy mind

Information on planning a healthy diet

Nursing care or physical therapy at home

Assistance with filling-out forms and paying medical bills

12. In regards to housing, I think the following services are IMPORTANT or will be important to me in the future (check all that apply):

Assistance in finding a nursing home

Assistance in finding an apartment

Assistance in finding an assisted living facility

Assistance in fixing things in home

13. In regards to employment, I think the following services are IMPORTANT or will be important to me in the future (check all that apply):

Assistance in finding a full-time job

Assistance in finding a part-time job

Assistance in getting job training

(job skills, resume, interviewing, grooming, etc.)

Other help I need with employment or may need in the future

(please write your answer in the space below):

14. In regards to activities, I think the following services are IMPORTANT or will be important to me in the future:

Information on senior center activities

Assistance in finding an exercise program

Assistance in finding things to do in town

15. Is there anything else you would like to tell us?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Thank you very much. Your input will make a big difference in the lives of older Alabamians.

PLEASE PRINT AND RETURN TO THE ADDRESS BELOW OR BY FAX TO 334-682-4045:

TIFFANY WALTERS

107 BROAD STREET

CAMDEN AL 3676

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