Getting to Know You - Safe at Home Questionnaire
Thank you for filling this out, so that our future programming will reflect your needs and interests. Your responses are anonymous unless you choose to provide your name at the end of the questionnaire.

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1. Age
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2. Gender
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3. Do you live alone?
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4. Do you care for another person in your household?
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5. Do you have a family member or friend that you are in regular contact with?
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6. If you have an emergency situation (such as a fall), do you have a way of contacting someone?
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7. Do you need help with activities of daily living?
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8. Do you have access to trusted helpers?
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9. Do you drive?
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10. Do you use a taxi or car service?
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11. If no, are you likely to want a taxi or car service in the future?
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12. Would you like a professional home safety assessment?
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13. Do you need food assistance, such as the local Food Pantry? (for reference:  https://regionalfoodbank.net and https://hillsdaleny.com/roe-jan-food-pantry/ )
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14. Do you know about the County Meals on Wheels Program?  (for reference:  https://sites.google.com/a/columbiacountyny.com/columbia-county-office-for-the-aging/home-delivered-meals )
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15. Do you need housing cost assistance? (eg rent subsidy, RE tax abatement, utilities)
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16. Have you contacted the Town Assessor, or otherwise received appropriate school and real estate tax benefits for seniors? (Pamela Cook, 518-325-5073 ext. 14)
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17. Did you attend our 2019 Safe at Home Workshop at the Firehouse?
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18. Have you attended our past "Coffee Hours"?
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19. If yes, which Coffee Hour program(s) did you find most engaging or useful?
20. Are you likely to attend a Coffee Hour in the future?
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21. Please list other social activities that might interest you:
22. Do you engage in the programs for seniors offered by the Roe Jan Community Library?  (for reference:  http://www.roejanlibrary.org/adult-programs/ )
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23. If Yes, which Library programs have you tried?
24. Have you received our "Guide for Home Maintenance and Repair" mailed out in January 2021?
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25. If Yes, is the Guide useful to you?
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26. If Yes, have you contacted anyone on the list of service providers?
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27. Do you want to receive periodic updates to the Resource Guide? If Yes (or if you never received a copy and would like one), please send an email request to HillsdaleSafeAtHome@gmail.com
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28. Do you know about resources available from the following agencies? (check all that apply)
29. Are you interested in learning about agencies and programs that assist seniors?
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30. Are there special needs you have, or think others may have, that Safe at Home should consider as we plan future activities and programs?
31. Are you interested in volunteering to help others in the community?  If Yes, please send an email to HillsdaleSafeAtHome@gmail.com
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32. What kind of volunteer activity interests you?
33. Is there anything you would like the Safe at Home Committee to know,  that was not covered in this questionnaire?
34. OPTIONAL: Your name, and contact info
Thank you!
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