Please share your views on the needs and services for senior adults living in our communities by completing this survey. Your responses may help determine future services for seniors in your community. Under each topic, place a “1” by the service you believe is most important to senior adults, a “2” by the second most important, and so forth.

1.    In Home Services:
        ____Housework & Personal Assistance.
        ____Adult Day Service (all day supervision and help in a community setting.)
        ____Companion Care.

2.    Health Care:
       ____Home Health/Nurses and Nurses Aide.
       ____Help in Purchasing Medications.
       ____Helping Seniors with Health Problems & Alcohol/Drugs/Smoking Cessation.
       ____Information on Health Issues & New Medications.

3.    Housing:
       ____Independent Community Living.
       ____Assisted Living Facilities.
       ____Home Renovation.
       ____Public Senior Housing.

4.    Financial Problems:
       ____Assistance in Writing Checks, Bill Payments, & Budgeting.
       ____Assistance in Applying for Benefits and Programs.
       ____Assistance Completing Medicare & Insurance Forms.

5.    Transportation:
       ____Transportation for Medical Appointments, Shopping, Visiting, etc.
       ____Transportation to Out-of-the-Area Medical Specialist & Treatment Centers.
       ____Setting Up a Volunteer Transportation Network.

6.    Mental Health Service:
       ____Support Groups for issues such as grief and loss.
       ____In-Home Mental Health Counseling.
       ____Counseling in Centers.
       ____Help & Support for Alcohol, Medication Misuse, & Smoking Cessation.

7.    Education & Recreation:
       ____Exercise, Dancing, & Walking Classes or Groups.
       ____Day Trips to Museums, Wineries, Historical Sites, etc.
       ____Learning Computer Basics.
       ____Other Classes or Activities (Suggestions).  ________________________________________

Please rank the following services in order of their importance. Place a “1” by the most important, a “2” by the second most important, and so forth:

        ____Home Delivered Meals.
       ____Congregate Meals at a Center.
       ____Crime Issues, Scams, Fraud, Personal Safety, & Safety Education.
       ____Legal Service, Wills, Powers of Attorney, & Mediation.
       ____Information & Assistance & Outreach to Senior Adults.
       ____Help with problems in Nursing Homes, Residents Rights & Councils.
       ____Elder Abuse, Neglect, & Financial Exploitation.
       ____Information on Re-entry to the Workforce.

We would appreciate comments about any of the topics addressed in this survey or about any other issues you feel are relevant. Do you have any comments about services or gaps in services for seniors? We are also interested in any comments you have on caregiving issues or problems that families and seniors face.

THANK YOU!