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

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

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

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

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

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

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

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

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

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?