1. What is your age?
2. Are you …
3. What is your race?
4. How often do you work with seniors?
5. Do you most often work with seniors as the:
6. Besides agencies, who do you find helps seniors most often?
Next, please help us understand the services which help senior adults by filling out the
second page and sharing your thoughts below about the issues which concern you
the most about senior adults.
| Please circle the number at the right that best describes the needs of senior adults. |
Very Important to seniors |
Somewhat Important to seniors |
Not Important to seniors |
| MEALS AND NUTRITIONAL NEEDS ... |
| Socializing at the senior center |
3 |
2 |
1 |
| Meals at the senior center |
3 |
2 |
1 |
| Availability of home delivered meals |
3 |
2 |
1 |
| Having enough food in the house |
3 |
2 |
1 |
| Food pantries to help stretch my food budget |
3 |
2 |
1 |
| Food stamps (Illinois LINK Card) |
3 |
2 |
1 |
| TRANSPORTATION ISSUES ... |
| Transportation to senior center, doctor, shopping, etc. |
3 |
2 |
1 |
| Transportation for out-of-the-area medical treatment |
3 |
2 |
1 |
| MENTAL HEALTH SERVICES ... |
| Help with issues such as grief and loss |
3 |
2 |
1 |
| Someone to talk to about problems and worries |
3 |
2 |
1 |
| Finding a support group |
3 |
2 |
1 |
| Having a counselor come to my home |
3 |
2 |
1 |
| Speaking with a counselor in the senior center |
3 |
2 |
1 |
| EDUCATION & RECREATION ISSUES ... |
| Exercise, dancing, & walking groups and classes |
3 |
2 |
1 |
| Day trips for entertainment, site seeing, etc. |
3 |
2 |
1 |
| Learning more about computers |
3 |
2 |
1 |
| OTHER ISSUES ... |
| Help taking care of a spouse or loved one |
3 |
2 |
1 |
| Obtaining an emergency response system |
3 |
2 |
1 |
| Help with dental care |
3 |
2 |
1 |
| Help paying for medications |
3 |
2 |
1 |
| Help fixing up my house |
3 |
2 |
1 |
| Help writing checks to pay bills |
3 |
2 |
1 |