In what part of town do you reside?
[name of neighborhood]What is your age (in years)?
Please rate the following as they relate to your life in [Town Name].
| Poor | Fair | Average | Good | Excellent | Do not know | |
|---|---|---|---|---|---|---|
| Your community as a place to live | ||||||
| Your community as a place to retire | ||||||
| Accessibility of public buildings | ||||||
| Availability of public restrooms | ||||||
| Places to sit and rest in downtown areas | ||||||
| Accessibility of small businesses and restaurants |
Do you have parks or outdoor public spaces in your neighborhood?
YesHow often did you visit a public park in the past year?
NeverPlease mention any locations in your community that you perceive as being particularly age-friendly.
Please mention any locations in your community that you perceive as NOT age-friendly.
Please rate the following as they relate to transportation in [Town Name]
| Poor | Fair | Average | Good | Excellent | Do not know | |
|---|---|---|---|---|---|---|
| Convenience of vehicular travel for you | ||||||
| Convenience of bus travel for you | ||||||
| Availability of bus stops for you | ||||||
| Ease of walking to access locations in your community | ||||||
| Ease of getting to the places you usually have to visit (e.g. grocery store, dr's office, pharmacy, etc.) | ||||||
| Affordability of public transport for you | ||||||
| Bus drivers are courteous to older people | ||||||
| Information on bus routes and schedules is available and easily accessible to you | ||||||
| City areas and services you need are accessible by public transport | ||||||
| Availability of door-to-door transportation for you |
In the last year, how often did you engage in the following:
| Never | Seldom | Sometimes | Often | Always | Do not know | |
|---|---|---|---|---|---|---|
| Use a vehicle to drive yourself | ||||||
| Ride in a vehicle driven by someone else | ||||||
| Ride a bus | ||||||
| Walk to a destination | ||||||
| Ride a bike | ||||||
| Use senior transportation or transportation for individuals with disabilities | ||||||
| Use paid services such as taxis, etc. |
Please rate the following as they relate to housing in [Town Name]
| Poor | Fair | Average | Good | Excellent | Do not know | |
|---|---|---|---|---|---|---|
| Availability of housing options | ||||||
| Availability of affordable quality housing | ||||||
| Availability of housing for low income seniors | ||||||
| Availability of retrofit homes for accessibility and safety | ||||||
| Ability to accomplish housework on your own or with assistance from others | ||||||
| Having the financial resources to maintain your home | ||||||
| Ability to maintain your yard on your own or with assistance from others |
Have you fallen in your home?
YesWhat are the causes of falls in your home?
Please rate the following as they relate to social participation in [Town Name]
| Poor | Fair | Average | Good | Excellent | Do not know | |
|---|---|---|---|---|---|---|
| Opportunities for you to enroll in skill building or personal enrichment classes | ||||||
| Recreation opportunities for you (arts, games, library services, etc.) | ||||||
| Fitness opportunities for you (exercise classes, trails, etc.) | ||||||
| Opportunities for you to attend social events or activities | ||||||
| Opportunities for you to attend religious or spiritual activities |
During a typical month, how often do you do the following?
| Never | Seldom | Sometimes | Often | Always | Do not know | |
|---|---|---|---|---|---|---|
| Communicate/visit with friends or family | ||||||
| Participate in religious or spiritual activities with others | ||||||
| Participate in recreation, educational program, or group activity | ||||||
| Volunteer in your community | ||||||
| Use a recreation center in your community | ||||||
| Use fitness center or gym in your community | ||||||
| Visit a local park or trail/nature walk | ||||||
| Use a public library in your community | ||||||
| Use other venues in your community for social participation (e.g. VFW, community centers, senior centers) |
Please rate the following as they relate to respect and social inclusion in [Town Name]
| Poor | Fair | Average | Good | Excellent | Do not know | |
|---|---|---|---|---|---|---|
| Valuing older residents in your community | ||||||
| Availability of people to reach out to for help if needed | ||||||
| Consideration for older residents' needs at local events and gatherings | ||||||
| Sense of community | ||||||
| Openness and acceptance of the community towards older residents of diverse backgrounds | ||||||
| Overall feeling of safety | ||||||
| Availability of resources to prevent potential fraud or scams | ||||||
| Having support when dealing with a difficult situation or substantial life event (health condition, loss of loved one, etc.) |
During a typical month, how often do you feel:
| Never | Seldom | Sometimes | Often | Always | Do not know | |
|---|---|---|---|---|---|---|
| Disrespected | ||||||
| Alone or isolated | ||||||
| Socially excluded | ||||||
| Unsafe |
Please rate the following as they relate to civic participation and employment in [Town Name]
| Poor | Fair | Average | Good | Excellent | Do not know | |
|---|---|---|---|---|---|---|
| Opportunities for you to attend and/or participate in local government meetings or other civic meetings | ||||||
| Availability of employment opportunities for you | ||||||
| Quality of employment opportunities for you | ||||||
| Opportunities for meaningful volunteer work for you | ||||||
| Having enough money to meet your daily expenses |
In the last 12 months, how often have you:
| Never | Seldom | Sometimes | Often | Very Often | Do not know | |
|---|---|---|---|---|---|---|
| Attended a meeting of your community's local elected officials or other local public meetings | ||||||
| Watched a meeting of your community's local elected officials or other public meeting on television, internet, or other media | ||||||
| Volunteered in your community | ||||||
| Served on city council, a citizen advisory council, neighborhood associations, or other civic organizations/committees |
Please rate the following as they relate to communication and information in [Town Name]
| Poor | Fair | Average | Good | Excellent | Do not know | |
|---|---|---|---|---|---|---|
| Availability of information about resources for older adults | ||||||
| Availability of financial or legal planning services for older adults | ||||||
| Having adequate information for dealing with public programs such as Social Security, Medicare, etc. | ||||||
| Knowing where to go if you need help filling out a form | ||||||
| Information in public areas are available and easy to read | ||||||
| Feeling informed about leisure and recreational activities available in your community |
How do you currently get information on programs and services? (check all that apply)
Free hardcopy newspapersPlease rate the following as they relate to community support and health services in [Town Name]
| Poor | Fair | Average | Good | Excellent | Do not know | |
|---|---|---|---|---|---|---|
| Availability of physical health care for you | ||||||
| Affordability of physical health care for you | ||||||
| Quality of your physical health care | ||||||
| Availability of mental health care for you | ||||||
| Quality of dental health care | ||||||
| Availability of preventative health services (e.g. health screenings, flu shots, education workshops) | ||||||
| Availability of affordable quality food | ||||||
| Being able to afford the medications you need | ||||||
| Getting the oral healthcare that you need | ||||||
| Being able to maintain a healthy diet | ||||||
| Being able to obtain affordable health insurance | ||||||
| Being able to stay physically fit | ||||||
| How would you rate your overall health status? |
What type of housing do you live in?
Single family homeHow many members in your household?
How many years have you lived in your community?
What is your employment status?
Working full time for payWhat category is your current or former occupation in?
Agriculture, Forestry, Fishing, and Hunting