[Sussex County NJ] Needs Assessment

Sussex County Department of Health & Human Services

Division of Senior Services

One Spring Street, 1st Floor, Newton, NJ, 07860

Phone: 973-579-0555 Fax: 973-570-0550

Email: seniorservices@sussex.nj.us

Needs Assessment Survey

As the Area Agency on Aging, the Sussex County Division of Senior Services is always trying to assess the need for supportive services among people 60 years of age and over.

Please take a few moments to fill out both sides of this survey form. You need not give your name, but if you would like information, please include your name and address so that we can contact you. When you finish completing the survey, return it no later than May 1, 2024. Thank you for your input!

Gender:

Male

Female

Town/City

Marital Status:

Single

Married

Widowed

Seperated/Divorced

Residence:

Own Home

Rent Apartment/House

Subsidized Housing

Living Situation:

Alone

With Spouse/Life Partner

With Adult Child

Income:

Less than $15,000

$15,000 - $24,999

$25,000 - $39,999

$40,000 - $59,999

$60,000 - $75,000

Over $75,000

Ethnicity

African American

Asian

Caucasian

Hispanic

For the following questions, indicate whether a given situation is or is not a problem for YOU, personally:

Health/Health Insurance

Not a Problem

Sometimes a Problem

Frequently a Problem

Not Applicable

Taking care of yourself (bathing, dressing, etc.)

Taking care of yourself (bathing, dressing, etc.)/Not a Problem

Taking care of yourself (bathing, dressing, etc.)/Sometimes a Problem

Taking care of yourself (bathing, dressing, etc.)/Frequently a Problem

Taking care of yourself (bathing, dressing, etc.)/Not Applicable

Obtaining home health services

Obtaining home health services/Not a Problem

Obtaining home health services/Sometimes a Problem

Obtaining home health services/Frequently a Problem

Obtaining home health services/Not Applicable

Discussing health related issues with your doctor

Discussing health related issues with your doctor/Not a Problem

Discussing health related issues with your doctor/Sometimes a Problem

Discussing health related issues with your doctor/Frequently a Problem

Discussing health related issues with your doctor/Not Applicable

Ability to participate in physical activity 3 times per week

Ability to participate in physical activity 3 times per week/Not a Problem

Ability to participate in physical activity 3 times per week/Sometimes a Problem

Ability to participate in physical activity 3 times per week/Frequently a Problem

Ability to participate in physical activity 3 times per week/Not Applicable

Ability to eat a balanced diet of lean meats, fruits/vegetables and whole grains

Ability to eat a balanced diet of lean meats, fruits/vegetables and whole grains/Not a Problem

Ability to eat a balanced diet of lean meats, fruits/vegetables and whole grains/Sometimes a Problem

Ability to eat a balanced diet of lean meats, fruits/vegetables and whole grains/Frequently a Problem

Ability to eat a balanced diet of lean meats, fruits/vegetables and whole grains/Not Applicable

Accessing preventative health services (vaccines/screenings)

Accessing preventative health services (vaccines/screenings)/Not a Problem

Accessing preventative health services (vaccines/screenings)/Sometimes a Problem

Accessing preventative health services (vaccines/screenings)/Frequently a Problem

Accessing preventative health services (vaccines/screenings)/Not Applicable

Having adequate health insurance/dental coverage

Having adequate health insurance/dental coverage/Not a Problem

Having adequate health insurance/dental coverage/Sometimes a Problem

Having adequate health insurance/dental coverage/Frequently a Problem

Having adequate health insurance/dental coverage/Not Applicable

Having prescription coverage

Having prescription coverage/Not a Problem

Having prescription coverage/Sometimes a Problem

Having prescription coverage/Frequently a Problem

Having prescription coverage/Not Applicable

Understanding health insurance/prescription coverage

Understanding health insurance/prescription coverage/Not a Problem

Understanding health insurance/prescription coverage/Sometimes a Problem

Understanding health insurance/prescription coverage/Frequently a Problem

Understanding health insurance/prescription coverage/Not Applicable

Keeping up with medical costs

Keeping up with medical costs/Not a Problem

Keeping up with medical costs/Sometimes a Problem

Keeping up with medical costs/Frequently a Problem

Keeping up with medical costs/Not Applicable

Income

Not a Problem

Sometimes a Problem

Frequently a Problem

Not Applicable

Having enough money for food, shelter or clothing

Having enough money for food, shelter or clothing/Not a Problem

Having enough money for food, shelter or clothing/Sometimes a Problem

Having enough money for food, shelter or clothing/Frequently a Problem

Having enough money for food, shelter or clothing/Not Applicable

Ability to pay for heat and other utilities

Ability to pay for heat and other utilities/Not a Problem

Ability to pay for heat and other utilities/Sometimes a Problem

Ability to pay for heat and other utilities/Frequently a Problem

Ability to pay for heat and other utilities/Not Applicable

Knowing who to contact for help with household budgeting/finances

Knowing who to contact for help with household budgeting/finances/Not a Problem

Knowing who to contact for help with household budgeting/finances/Sometimes a Problem

Knowing who to contact for help with household budgeting/finances/Frequently a Problem

Knowing who to contact for help with household budgeting/finances/Not Applicable

Housing

Not a Problem

Sometimes a Problem

Frequently a Problem

Not Applicable

Cleaning/tidying your home

Cleaning/tidying your home/Not a Problem

Cleaning/tidying your home/Sometimes a Problem

Cleaning/tidying your home/Frequently a Problem

Cleaning/tidying your home/Not Applicable

Maintaining your home (shoveling, mowing, small repairs, etc.)

Maintaining your home (shoveling, mowing, small repairs, etc.)/Not a Problem

Maintaining your home (shoveling, mowing, small repairs, etc.)/Sometimes a Problem

Maintaining your home (shoveling, mowing, small repairs, etc.)/Frequently a Problem

Maintaining your home (shoveling, mowing, small repairs, etc.)/Not Applicable

Being able to pay for home repairs

Being able to pay for home repairs/Not a Problem

Being able to pay for home repairs/Sometimes a Problem

Being able to pay for home repairs/Frequently a Problem

Being able to pay for home repairs/Not Applicable

Obtaining affordable housing

Obtaining affordable housing/Not a Problem

Obtaining affordable housing/Sometimes a Problem

Obtaining affordable housing/Frequently a Problem

Obtaining affordable housing/Not Applicable

Safety/Healthcare

Not a Problem

Sometimes a Problem

Frequently a Problem

Not Applicable

Avoiding accidents/hazards in the home (ex: falling)

Avoiding accidents/hazards in the home (ex: falling)/Not a Problem

Avoiding accidents/hazards in the home (ex: falling)/Sometimes a Problem

Avoiding accidents/hazards in the home (ex: falling)/Frequently a Problem

Avoiding accidents/hazards in the home (ex: falling)/Not Applicable

Access to in county non-emergency medical care

Access to in county non-emergency medical care/Not a Problem

Access to in county non-emergency medical care/Sometimes a Problem

Access to in county non-emergency medical care/Frequently a Problem

Access to in county non-emergency medical care/Not Applicable

Ability to fill/take medication as prescribed

Ability to fill/take medication as prescribed/Not a Problem

Ability to fill/take medication as prescribed/Sometimes a Problem

Ability to fill/take medication as prescribed/Frequently a Problem

Ability to fill/take medication as prescribed/Not Applicable

Having an emergency preparedness plan in place that others are aware of

Having an emergency preparedness plan in place that others are aware of/Not a Problem

Having an emergency preparedness plan in place that others are aware of/Sometimes a Problem

Having an emergency preparedness plan in place that others are aware of/Frequently a Problem

Having an emergency preparedness plan in place that others are aware of/Not Applicable

Transportation

Not a Problem

Sometimes a Problem

Frequently a Problem

Not Applicable

Transportation for doctor visit, shopping, etc.

Transportation for doctor visit, shopping, etc./Not a Problem

Transportation for doctor visit, shopping, etc./Sometimes a Problem

Transportation for doctor visit, shopping, etc./Frequently a Problem

Transportation for doctor visit, shopping, etc./Not Applicable

Using public transportation (bus/rail)

Using public transportation (bus/rail)/Not a Problem

Using public transportation (bus/rail)/Sometimes a Problem

Using public transportation (bus/rail)/Frequently a Problem

Using public transportation (bus/rail)/Not Applicable

Driving my own vehicle wherever I need to go

Driving my own vehicle wherever I need to go/Not a Problem

Driving my own vehicle wherever I need to go/Sometimes a Problem

Driving my own vehicle wherever I need to go/Frequently a Problem

Driving my own vehicle wherever I need to go/Not Applicable

Family Support/Caregiver

Not a Problem

Sometimes a Problem

Frequently a Problem

Not Applicable

Over the age of 60 and receiving care/assistance from an adult family member/friend

Over the age of 60 and receiving care/assistance from an adult family member/friend/Not a Problem

Over the age of 60 and receiving care/assistance from an adult family member/friend/Sometimes a Problem

Over the age of 60 and receiving care/assistance from an adult family member/friend/Frequently a Problem

Over the age of 60 and receiving care/assistance from an adult family member/friend/Not Applicable

Over the age of 60 and providing care to: An older adult (age 60+)

Over the age of 60 and providing care to: An older adult (age 60+)/Not a Problem

Over the age of 60 and providing care to: An older adult (age 60+)/Sometimes a Problem

Over the age of 60 and providing care to: An older adult (age 60+)/Frequently a Problem

Over the age of 60 and providing care to: An older adult (age 60+)/Not Applicable

A disabled child

A disabled child/Not a Problem

A disabled child/Sometimes a Problem

A disabled child/Frequently a Problem

A disabled child/Not Applicable

Grandchild (full responsibility)

Grandchild (full responsibility)/Not a Problem

Grandchild (full responsibility)/Sometimes a Problem

Grandchild (full responsibility)/Frequently a Problem

Grandchild (full responsibility)/Not Applicable

General Information

Not a Problem

Sometimes a Problem

Frequently a Problem

Not Applicable

Knowing where to turn for information on benefits/services/legal services/programs for seniors

Knowing where to turn for information on benefits/services/legal services/programs for seniors/Not a Problem

Knowing where to turn for information on benefits/services/legal services/programs for seniors/Sometimes a Problem

Knowing where to turn for information on benefits/services/legal services/programs for seniors/Frequently a Problem

Knowing where to turn for information on benefits/services/legal services/programs for seniors/Not Applicable

Substance Abuse/Tobacco

Not a Problem

Sometimes a Problem

Frequently a Problem

Not Applicable

Does substances/alcohol affect your daily life?

Does substances/alcohol affect your daily life?/Not a Problem

Does substances/alcohol affect your daily life?/Sometimes a Problem

Does substances/alcohol affect your daily life?/Frequently a Problem

Does substances/alcohol affect your daily life?/Not Applicable

Does the use of tobacco products affect your health?

Does the use of tobacco products affect your health?/Not a Problem

Does the use of tobacco products affect your health?/Sometimes a Problem

Does the use of tobacco products affect your health?/Frequently a Problem

Does the use of tobacco products affect your health?/Not Applicable

Mental Health

Not a Problem

Sometimes a Problem

Frequently a Problem

Not Applicable

Do mental health symptoms affect your daily life?

Do mental health symptoms affect your daily life?/Not a Problem

Do mental health symptoms affect your daily life?/Sometimes a Problem

Do mental health symptoms affect your daily life?/Frequently a Problem

Do mental health symptoms affect your daily life?/Not Applicable

Do you have access to social/recreational activities?

Do you have access to social/recreational activities?/Not a Problem

Do you have access to social/recreational activities?/Sometimes a Problem

Do you have access to social/recreational activities?/Frequently a Problem

Do you have access to social/recreational activities?/Not Applicable

If you would like someone to contact you for information regarding service/benefits to seniors, please include your name and telephone number below:

Phone Number

Any additional comments?