APPENDIX F
SENIOR NEEDS SURVEY
Austin and Travis County Need Your Help to Plan for the Future. Please fill out the following survey if you are age 55 or older.
1. Do you use or receive any of the following?
- Special buses or vans
- Public housing
- In-home care
- Free meals or groceries
- Home repair
- Medicare
- Legal help
- Housecleaning
- Medicaid/MAP clinic card
- Social Security checks
- Caregiver respite
- Medigap/extra insurance
- Food stamps
- Social activities
- Help paying rent/bills
- NONE
- Other (please describe) ___________________
2. What kinds of services do you need that you are not getting now?
- Special buses or vans
- Public housing
- In-home care
- Free meals or groceries
- Home repair
- Medicare
- Legal help
- Housecleaning
- Medicaid/MAP clinic card
- Social Security checks
- Caregiver respite
- Medigap/extra insurance
- Food stamps
- Social activities
- Help paying rent/bills
- NONE
- Other (please describe) ___________________
3. Of the services listed above, which three (3) are the most important to you?
4. What could be done to make the services listed better or easier to use?
5. What are the biggest problems that keep you from getting what you want or need?
6. What types of activities would you like to be doing that you are not already doing?
- Arts and crafts
- Reading
- Social groups
- Group sports
- Gardening
- Classes/education
- Volunteering
- Walking
- Cooking
- Music
- Bible study/prayer
- Swimming m Travel
- Computer classes/access to computers
- Other (please describe) __________________________________________________
7. Who do you usually turn to when you need help?
- Relative m Friend/ Neighbor
- Professional Caregiver
- Social Worker
- Non-profit Agency
- Don't have anyone to help
- Other (please describe) _______________________________________________
8. Which programs or agencies have helped you the most in the past year?
9. What is your primary language?
- English
- Spanish
- Other ___________________________
10. Has your language or culture ever made it difficult for you to obtain services?
- Never
- Rarely
- Sometimes
- Many times
- Most of the time
11. Where do you live? Zip code _____________________________
- Within the Austin city limits m Outside the Austin city limits, but within Travis County
- Outside Travis County in _____________________ County
- Other _____________________
12. What is your living situation?
- In my own house, alone
- In my own apartment or condo, alone
- In a relative's house, apartment, etc.
- In my own house with your spouse, significant other, relative, or roommate
- In my own apartment/condo with spouse, significant other, relative or roommate
- In an assisted living or nursing care facility
- In a retirement community
13. What would be your ideal living situation?
- In my own house, alone
- In my own apartment or condo, alone
- In a relative's house, apartment, etc.
- In my own house with your spouse, significant other, relative, or roommate
- In my own apartment/condo with spouse, significant other, relative or roommate
- In an assisted living or nursing care facility
- In a retirement community
14. What is your age?
- 55-59
- 60-69
- 70-79
- 80 or older.
15. What is your race/ethnicity? (check one)
- m African-American (Black)
- Hispanic m Caucasian (White)
- Asian American
- Other _________________________________________
16. What is your gender?
17. What is your total household income per month? Include all sources of income including social security, your spouse's income, and any extra income.
- Less than $695
- $696 to $1042
- $1043 to $1390
- $1391 to $2085
- $2086 to $2780
- $2781 and over
18. Are you caring for someone in your home whom is unable to take care of themselves?
- Yes
- No
- a. If yes, what is that person(s)' relationship to you?
- My wife or husband
- My parent or parent-in-law
- Other (please specify) _____________________________
Thank you for participating in this survey. This survey is part of a community assessment, the Aging Services Environment Scan project, being conducted by St. David's Foundation, United Way/Capital Area and Travis County Health and Human Services & Veteran's Services.
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