Senior Needs Survey

Question Title

* 1. In what county do you live?

Caddo

Comanche

Cotton

Grady

Jefferson

McClain

Stephens

Tillman

Other (please specify)

Question Title

* 2. Are you male or female?

Male

Female

Question Title

* 3. How old are you or the typical client you serve?

Under 60

60 and older

Question Title

* 4. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Other (please specify)

Question Title

* 5. How did you first hear about ASCOG Area Agency on Aging?

Newspaper

Word of mouth

ASCOG presentation

Other (please specify)

Question Title

* 6. From the list below, please rank the services from most important to least important for older persons and those who serve them.

Access to Health Care

N/A

Affordable Housing

N/A

Buying Prescription Medications

N/A

Caregive Support Groups

N/A

Caregiver Respite Vouchers

N/A

Employment Programs

N/A

Exercise/Wellness

N/A

Help to Understand Medicare/Medicaid/Social Security Benefits

N/A

Help with Dentures, Hearing Aids and/or Eyeglasses

N/A

Help with Utility Bills

N/A

Home Delivered Meals

N/A

Home Emergency Alert Response Systems

N/A

Homemaker/Chore Services

N/A

Information and Assistance

N/A

Legal Assistance

N/A

Meals for Caregivers

N/A

Mental Health Services and Counseling

N/A

Nutrition Education/Counseling

N/A

Nutrition/Senior center on-site meals

N/A

Other

N/A

Personal Care Bathing

N/A

Recreation and Socialization

N/A

Training for Caregivers and Grandparents Raising Grandchildren

N/A

Transportation

N/A

Question Title

* 1. In what county do you live?

Question Title

* 2. Are you male or female?

Question Title

* 3. How old are you or the typical client you serve?

Question Title

* 4. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

Question Title

* 5. How did you first hear about ASCOG Area Agency on Aging?

Question Title

* 6. From the list below, please rank the services from most important to least important for older persons and those who serve them.

Question Title

* 7. Please write any additional comments here.