Need Assessment Form
Kupuna Care Post Covid-19 Program on Molokai
Funded by County of Maui, Office of Economic Development

Molokai Rural Health Community Association

Your response will help guide the development of services for our kupuna.  This survey should take about 10 minutes.  All the information you provide will be kept confidential.  Findings will be presented as summaries, without any personal identification information.  
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Name *
Phone Number *
Physical Address *
Mailing Address *
Email Address *
Which category best describes you? *
Which district do you live in? *
How many years have you lived on Molokai? *
How would you rate Molokai as a place to live for people as they age? *
What do you feel are the top three needs to be addressed so that kupuna can continue to live independently on Molokai? *
IF YOU ARE A FAMILY CAREGIVER, what is the greatest challenge encountered in providing care for your loved one?
Where do you get information about services available for kupuna on Molokai? Check all that apply. *
Required
Please rate the following issues as they relate to kupuna on Molokai...
Health, Medication & Medical Supplies *
Finances & Cost of Living *
Scams & Fraud *
Transportation *
Activities of Daily Living *
Information About Services Available to Kupuna *
Food & Nutrition *
Public Benefits *
Home Repairs for Health & Safety *
Depression, Loneliness or Isolation *
Medical and Legal Assistance *
Housing *
Exercise & Recreation Activities *
Social Interaction with Family or Peers *
Are there any other concerns you feel are important to address for kupuna on Molokai?
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