2009 Survey of
Older Adults and their Caregivers


Purpose:
Your input is important! This survey is only done once every four years, and the results help decide which senior programs and services get funds.

Instructions:

Please answer all the questions as best you can. If you have already done this survey, don’t do it again. It takes about 20 minutes to finish.

This survey is Anonymous. Nobody will know which survey was yours. If you still feel uncomfortable answering a question, just leave it blank.

Your survey must be received by January 15th, 2010 to be counted.

Contact Information

If you have questions or need help, contact Terri Deits at (707) 644-6612 x17

We would like to acknowledge A4AA Sacramento Area Agency on Aging for creating the survey from which this was adapted.


Which county do you reside?

Which city do you reside?

Other:

Part 1: Your Health and Wellness

1) Are you filling out this survey for yourself?

If No, ask the senior each question as it is written, then mark their answer.

2) Overall, how would you describe your health right now?

3) During a typical week, how many days do you do any moderate physical activities for at least 10 minutes?
(Moderate physical activities make you breathe harder than normal.)

4) In a typical day, how many times do you eat foods that are healthy for you
(such as a piece of fruit, a glass of low-fat milk, a serving of chicken with no skin and no breading)?

5) How would you describe your memory?

6) During the past 30 days, about how often did you feel sad, lonely or depressed?

7) Are you limited in any way in any activities because of physical, mental, or emotional problems?

8) Do you have any chronic health problems? (Check all that apply)
Arthritis
Asthma
Cancer
Diabetes
Eye disease
 		Heart disease
Hypertension
Osteoporosis
Stroke
None of these
Other:

9) How many different prescription medications do you take?

10) What type of health insurance do you have? (Check all that apply)
No insurance
Medi-Cal
 		Retiree plan
Tricare
Long Term Care Policy
Medicare
      Part A
      Part B
 		Medicare
      Part C (HMO/PPO)
      Part D (Drugs)
Other:

11) Which documents do you have?
Advance Directive (for health care)
Power of Attorney (for finances)
Will or Trust
 		None of these

12) In the past 12 months, has someone taken advantage of you in any way?

If Yes, what did you do?

Other:

13) Have you fallen in the past 12 months?

If Yes, what happened?

14)(a) Do you provide unpaid care for a family member or friend?

If No, skip to Part 2, #1

15)(a) Whom do you help care for? (Check all that apply)
A spouse or partner
A disabled son or daughter
A grandchild you are raising
Other:

(b) Altogether, how often do you help?

Part 2: You and Your Household

1) What is your sex?

2) What month and year were you born?:

3) What is your racial/ethnic background?
(If more than one, check all that apply)
Alaskan Native/American Indian
Asian (from Far East, Southeast, or India)
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White (from Europe, Russia, Middle East)
Other:

4) What language do you speak at home?
English
 		Spanish
Other:

5) What is your highest level of education?

6) Are you a veteran?

7) What is your work status?

8) If you volunteer, about how many hours a month do you volunteer?

9) What is your monthly income?
(a) As a Married Couple (before taxes):
(b) OR, as a Single Person (before taxes):

10) Where does your income come from?
Wages
Pension
Investments
 		Social Security
SSI/SSP
Other:

11) Do you usually have enough money to pay for your regular expenses?

If no, what things do you cut back on?
Food
Medicine
Medical Bills
 		Gasoline
Credit Card Bills
Other:

12) What is your zip code?

13) How many years have you lived in Napa or Solano County?

14) How many years have you lived in the United States?

15) What is your current marital status?

16(a) Whom do you live with (either in your home or in theirs) (Check all that apply)
Spouse/Partner
Son/Daughter
 		I live alone
Other:
(b) Is your spouse/partner age 60 or older?

17) How do you pay for housing?
My home is paid off
I pay a mortgage
 		I pay rent
Other:

18) Do you spend more than 30% of your yearly income on housing (including rent or your mortgage and property taxes)?

19) Do you live in a “seniors only” area?

20) What kind of place do you live in?
House
Mobile home or modular home
Apartment/Condominium/Townhouse
Hotel/motel or trailer/camper
Assisted Living or Board & Care home
Other:

Part 3: Transportation

1) Could you take public transportation from where you live if you wanted to?

2) How would you describe your driving?

3) How do you usually get where you need to go (bank, doctor, etc.)?
Other:

Part 4: Daily Activities

1) Below is a list of activities that are difficult for some people. Check Yes or No for each item. If you do not have a spouse/partner, leave those columns blank.

Daily Activities I have
trouble
with this		 I get help
with this		   My spouse/
partner has
trouble
with this		 My spouse/
partner
gets help
with this
Eating Yes No Yes No   Yes No Yes No
Getting up from a chair Yes No Yes No   Yes No Yes No
Using the toilet Yes No Yes No   Yes No Yes No
Getting in and out of bed Yes No Yes No   Yes No Yes No
Walking across a room Yes No Yes No   Yes No Yes No
Bathing or showering Yes No Yes No   Yes No Yes No
Getting up and down stairs Yes No Yes No   Yes No Yes No
Preparing meals Yes No Yes No   Yes No Yes No
Shopping Yes No Yes No   Yes No Yes No
Using a telephone Yes No Yes No   Yes No Yes No
Reading (using glasses if applicable) Yes No Yes No   Yes No Yes No
Managing money (balancing a checkbook) Yes No Yes No   Yes No Yes No
Managing medications Yes No Yes No   Yes No Yes No
Light housework (vacumming, dishes, etc.) Yes No Yes No   Yes No Yes No
Heavy housework (laundry, windows, etc.) Yes No Yes No   Yes No Yes No

2) Are you and/or your spouse or partner unable to get the help that you need with any of these daily activities for any reason?

Part 5: Needs and Concerns

1) Below is a list of things that could trouble you and/or your spouse or partner. Please circle the best answers to show which things are an issue AND if help is needed with them.
Things that Concern Seniors Is this an issue for you
and/or your spouse or
partner Right Now?		   Do you
need HELP
with this?
Being able to continue living in my home Yes No Doesn't apply   No Yes
Finding services or benefits that could help me Yes No Doesn't apply   No Yes
Planning for future long term care needs Yes No Doesn't apply   No Yes
Getting help with wills, trusts, powers of attorney Yes No Doesn't apply   No Yes
Being able to continue driving a car safely Yes No Doesn't apply   No Yes
Getting transportation for errands (bank, etc.) Yes No Doesn't apply   No Yes
Getting transportation for medical appointments Yes No Doesn't apply   No Yes
Paying for housing Yes No Doesn't apply   No Yes
Getting minor home repairs and/or modifications Yes No Doesn't apply   No Yes
Getting someone to do major home repairs Yes No Doesn't apply   No Yes
Getting someone to do yard work Yes No Doesn't apply   No Yes
Having a serious fall Yes No Doesn't apply   No Yes
Getting the kind of medical care that I/we need Yes No Doesn't apply   No Yes
Paying for medical care (doctor/hospital bills) Yes No Doesn't apply   No Yes
Paying for medicines (prescription drugs) Yes No Doesn't apply   No Yes
Understanding my health care options Yes No Doesn't apply   No Yes
Finding a reliable person to do in-home care Yes No Doesn't apply   No Yes
Paying out-of-pocket for in-home care Yes No Doesn't apply   No Yes
Paying out-of-pocket for care outside the home Yes No Doesn't apply   No Yes
Having enough food to eat Yes No Doesn't apply   No Yes
Paying for dental care Yes No Doesn't apply   No Yes
Finding a job Yes No Doesn't apply   No Yes
Caring for grandchildren Yes No Doesn't apply   No Yes
Dealing with dementia/Alzheimer’s disease Yes No Doesn't apply   No Yes
Dealing with loneliness or depression Yes No Doesn't apply   No Yes
Being taken advantage of financially Yes No Doesn't apply   No Yes
Being physically abused by someone Yes No Doesn't apply   No Yes
Being emotionally abused by someone Yes No Doesn't apply   No Yes

2(a) Which of the things on the previous page concerns you the most right now?


(b) Is there anything else that concerns you a great deal right now?


(c) Are there any issues that are not a concern for you now, but may become a serious problem
for you in the next 4 years? If so, please explain.


Part 6: Services You Use

1(a) Which of these services have you and/or your spouse or partner used in the last 12 months? (Check all that apply)
Adult Day Care (social only)
Adult Day Health Care (social and health)
Alzheimer’s day care
Caregiver services
Counseling services
Elder Abuse Services (APS, Victim Services)
Financial Abuse Services
Friendly visiting (such as Senior Companion)
Health insurance counseling (HICAP)
Hospice services
In-Home care (IHSS)
In-Home care (private pay)
Information & Assistance (1-800-510-2020)
Linkages
Meals on Wheels (Senior Nutrition Services)
Medication management
Mental health services
Minor home modification
Fall Prevention Services
  		MSSP
Ombudsman services
Respite care (of any kind)
Senior center activities
Senior Legal Hotline
Senior legal services
Senior lunch sites (Senior Nutrition Services)
Senior peer counseling program
Surplus food program (incl. Brown Bag)
Transportation
Fixed route bus/train
Para-transit
Medical transport
Taxi
HAPI Rides (Voucher)
Ride with Pride (Assist. Transportation)
AAA Escort
Veterans services
Volunteer Program
Other:

(b) Please make any comments about the services you received in the space below.

For FREE information about Senior Services in your area
Call 1-800-510-2020 or dial 2-1-1

Part 7: Seniors and Technology

1(a) Do you have access to a computer?

If yes, skip to #2.

(b) If no, do you feel that puts you at a disadvantage? (Select best answer, then skip to #7)

2(a) About how often do you use a computer?

(b) If never, why don’t you use a computer? (check all that apply, then skip to #7)
I don't know how
I don't need one
 		I can't afford one
I am afraid

3(a) About how often do you need help when you use the computer? (check best answer)

If Never, skip to #4.

(b) When you do need help, who usually helps you? (select the best answer)

Other:

4(a) About how often do you use e-mail? (select the best answer)

If Never, skip to #5.

(b) With whom do you communicate by e-mail? (check all that apply)
Family
Friends
Businesses
 		Social groups/clubs
My nurse/doctor
 

(c) Would you like to get information by e-mail from non-profit organizations that offer free programs and services for seniors?

5(a) About how often do you use the internet? (check the best answer)

If Never, skip to #6.

(b) Why do you use the internet? (check all that apply)
Getting news
Health information
Online services
Just for fun
 		Checking facts
Viewing maps
Chat rooms
Other:

(c) Have you ever tried to find information about local programs and services for seniors on the internet?

If No, skip to #6.

(d) If yes, what happened?

6) Do you worry about being scammed by someone through your e-mail or the internet?

7) How do you prefer to get information about senior programs and services in your area?
Local Daily Newspaper
Local newsletter
E-mail message
Senior Magazine
Neighborhood newsletter
 		Internet posting
Senior Spectrum
Local Weekly Newspaper
Other:  

~ Thank you for completing our survey ~