NCIHA Elder Village Development Survey Elder Village Question Title * 1. What is your Tribal Affiliation? Maidu Indian of Berry Creek Rancheria Guidiville Rancheria Hopland Band of Pomo Indians Kletsel Dehe Wintun Nation Manchester Point Arena Band of Pomo Indians Mooretown Rancheria of Maidu Indians Redwood Valley Little River Band of Pomo Indians Sherwood Valley Rancheria Band of Pomo Indians Wilton Rancheria Other (please specify) None of the above Question Title * 2. Are you an Elder? (60+ years old) Yes No Question Title * 3. How likely are you to live in an NCIHA Elder Village? Likely Neutral Unlikely Question Title * 4. Do you receive SSI/SSP? Yes No Question Title * 5. Do you receive any other forms of income? Select all those that apply. Retirement Part-Time Employment Full-Time Employment Rental Income (as a property owner) Business Income (business owner) In Home Supportive Services Tips Other (please specify) None of the above Question Title * 6. Do you require accessibility in your home? (i.e. wheelchair access, grab bars, walk-in shower, etc.) Yes No Question Title * 7. What traditional and cultural features would you like to see incorporated into the new elder living space? (i.e. traditional plants/medicine, basket patterns, etc.) Question Title * 8. What supportive services would you like to see offered in the elder village? Select all that apply. Healthcare services Cultural activities Transportation assistance Social support programs Nutritional support Other (please specify) Question Title * 9. What are your needs for visitor and gathering space in the elder village? Select all that apply. Picnic Area Arbor Patio Recreation Room Community Dining Community Kitchen Library Community Garden Other (please specify) Question Title * 10. What features would you like to see included in shared space within the Elder Village? Select all that apply. Accessibility (i.e. grab bars, ramps, wheelchair access, etc.) Public Transportation Communal Space Community Kitchen Walking Paths Maker's Space Library In-House Physical Therapy Access to Healthy and Traditional Foods Community Delivery Services Grocery Delivery Services Pharmacy Delivery Services Visitor Use Space (i.e. play equipment, picnic tables, patio, etc.) Community Garden Space (i.e. seasonal fruits and vegetables, herbs, traditional medicine, etc.) Other (please specify) None of the above Question Title * 11. What are some features that you would like to see in the living space offered to Elder? Select all that apply. Accessibility (i.e. grab bars, ramps, wheelchair access, walk-in shower, etc.) Pet Friendly Internet Cable Natural Lighting Neutral Colors Units that are Furnished One-bedroom, one-bath Two-bedrooms, one bath Other (please specify) Question Title * 12. This space is saved for additional thoughts and comments. We value and thank you for your honesty and participation. Question Title * 13. If you are intersted in being added to our Elder Village waiting list, please provide your name and contact information. Thank you. Name Mailing Address Email Phone Number Done