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Resident Needs Assessment Survey

Abuse in Later Life: Services and Support for Individuals Being Harmed

Our community has received funding from the Department of Justice’s Office on Violence Against Women to create or enhance services for older community members who are experiencing abuse in later life. Your ideas are important to us. Please answer as many of the questions below as you can. You do not need to sign your name. All of your answers are anonymous and confidential.

Individuals who are age 50 and older may be harmed in many ways including being hit, yelled at or sexually assaulted. They may be neglected or have money or possessions stolen. The person who is harming them is often someone they know; someone they love or trust, such as a spouse, partner, adult child or other family member or a caregiver. You may have been harmed or you may know someone who has been or is being harmed. If you want to talk to someone after taking this survey, ask staff about support and local resources.
Section A: Services That Might Be Helpful for Older Individuals Being Harmed
1.Please check the top three (3) services you think would be helpful for older individuals who are being hurt by a spouse, partner, adult child or family member or caregiver.
2.Where do you think would be a good place to hold services for older individuals who have been harmed? (Check all that apply.)
3.What hours should services be available? (Check all that apply)
4.What information could be helpful for older individuals who have been harmed? (Check all that apply)
5.How should we let older individuals know about available help? (check all that apply)
6.Where would you recommend putting up posters or leaving brochures? (Check all that apply)
7.What other suggestions do you have to help older individuals who are struggling with controlling and hurtful relationships?
Section B: Your Personal Experience
The questions below may be difficult to answer, but your answers will provide important information for us to consider for this community needs assessment. If the questions are too uncomfortable for you to answer, please feel free to skip this question. If you have been harmed by a spouse, partner, adult child or family member, or caregiver in any of the ways described in the left column, please check the box to indicate whether this happened before you turned 50 or after the age of 50. If you were harmed before and after 50, check both boxes. If this behavior has never happened to you, please leave the boxes blank. Remember – all your answers are private and confidential.
8.Have you ever had a spouse/partner, family member or caregiver take away your money, property or other assets without consent?
9.Have you ever been denied food, water, sleep, medication or medical care?
10.Have you ever been afraid of a spouse/partner, family member or caregiver?
11.Has a spouse/partner, family member or caregiver ever hit, punched, pushed you or otherwise physically hurt you?
12.Has a spouse/partner, family member or caregiver ever touched you in a way that made you feel uncomfortable or hurt you sexually in any way?
13.Has a spouse/partner, family member or caregiver constantly put you down (saying things like “you are stupid” or “no one else will love you”) or made fun of you?
Section C: Demographics
To help us make sure that we get a good representation from this community, please check the answers that best describe you below. Keep in mind all responses will be kept confidential.
14.Age:
15.Race:
16.Highest Level of Education:
17.Employment Status:
18.Annual Income:
Thank you for taking the time to complete this survey!


If you would like to talk to someone or ask about services, please talk to the staff distributing this survey.
This survey was revised by the National Clearinghouse on Abuse in Later Life (NCALL) and the Office on Violence Against Women (OVW) based on surveys created and implemented by the Division of Senior Services and Longmont Coalition for Women in Crisis and Project REACH, Partners for Elder Abuse Community Education (PEACE) in Portland, Maine.