Pennyrile Area Agency on Aging & Independent Living FY 18 Needs Assessment Survey
Please complete the entire survey. Surveys must be completed by October 31, 2017.
County of Residence:
Your answer
Ethnic Background:
Marital Status:
Yearly (Individual) Income Level:
Education Level:
Which categories best describe you? (Please check all that apply)
You live with:
Type of housing you live in:
Are you satisfied with your current living arrangement?
If "no", please explain:
Your answer
Current Health Status:
Types of health insurance you currently have: (Please check all that apply)
In the last year, you have needed help with: (Please check all that apply)
Who currently helps to provide care for you? (Please check all that apply)
Place a check mark to indicate whether a high priority or low priority should be placed on the following issues regarding senior citizens in your community.
High Priority
Low Priority
Don't Know
Meals in Senior Centers
Leagal Services
Benefits Counseling
Adult Day Care
Respite / Sitter Services
Home Health Services
Homemaking Services
Personal Care Services
Information / Assistance
Home Repair / Ramp
Home Delivered Meals
Volunteer Opportunities
Senior Center Services
Counseling Services
Senior Employment
Advocacy for Seniors
Support Groups
Are you now using or have you ever used any of the services listed above?
If "yes", please explain:
Your answer
If you were to be placed on a waiting list for services, would you be interested in private pay services until the funded service you need is available?
Are there any other needs you are aware of that are not currently being met for senior citizens within your community?
Your answer
Please add any additional comments or suggestions you have which may be useful in planning toward the future of the senior citizens in this area.
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms