2019 Aging in Place Survey

On behalf of our Aging in Place Committee, a committee represented by the City of Rawlins, Carbon County Economic Development, Carbon County Public Health, Wyoming Business Council, Senior Services and other providers and concerned citizens, we are seeking your input and/or desire for (affordable) senior, independent living housing and/or an assisted living facility for seniors and/or disabled. Please complete the survey below which will take no more than ten (10) minutes to complete. Please complete the survey by no later than June 10th. You can also return a hard copy to City of Rawlins, P.O. Box 953, Rawlins, WY 82301 by that date.
You may receive this survey through one of many sources, but please submit only ONCE so as not to skew the numbers.

Thank you.

Question Title

* 1. As the person completing this survey are you a senior citizen?

Yes

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* 2. As the person completing this survey are you disabled?

Yes

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* 3. Please indicate the age grouping of the person completing this survey:

0-25

26-45

46-55

56-60

61-70

71-75

76-80

81-85

86-90

91-95

96-99

100+

Question Title

* 4. In which town do you live?

Baggs

Dixon

Elk Mountain

Encampment

Hanna

Medicine Bow

Rawlins

Saratoga

Sinclair

Other (please specify)

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* 5. What is your current living arrangement?

Alone

With a spouse or partner

With a spouse or partner with children under the age of 18

With a spouse or partner with children over the age of 18

With another adult (not spouse or partner)

Single parent with children

With a professional care-giver (live-in only)

Other (please specify)

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* 6. Do you live in:

Low-income housing

Senior housing

A house that you own

A house or apartment that you rent

A skilled nursing facility/nursing home

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* 7. Do you feel safe where you live?

Yes

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* 8. Do you provide care-giving for an older or disabled adult?

Yes, a spouse or partner

Yes, an adult child

Yes, another adult (not spouse or child)

Other (please specify)

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* 9. Looking at our aging population’s greatest needs, how important would an Assisted Living Facility be to the City of Rawlins, on a scale of 1-5 ( 1 no need and 5 extremely high need)

1 (no need)

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* 10. Looking at our aging population’s greatest needs, how important would Senior Independent Living Housing be to the City of Rawlins, on a scale of 1-5 ( 1 no need and 5 extremely high)

1 (no need)

5 (extremely high need)

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* 11. Do you have any concerns/comments about an Assisted Living Facility being located in Rawlins?

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* 12. If an Assisted Living Facility was built in Rawlins, would you or someone you know be interested in living there?

Yes/self

Yes/other

Unsure

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* 13. If Senior Independent Housing Living Housing was built in Rawlins, would you or someone you know be interested in living there?

Yes/self

Yes/other

Unsure

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* 14. If interested in either, would you need Medicaid assistance or be private pay?

Yes, Medicaid Assistance

Private pay

Unsure

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* 15. If private pay, what price range could you or a family member afford to pay/month?

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* 16. If interested in Assisted Living Facility or Senior Independent Living Housing, what would be your

individual needs? (please check all that apply)

Safe living environment

Medication administration

Physical therapy/occupational therapy

Fitness routine

Socialization

Nutrition assistance

Emergency medical

Transportation

Other (please specify)

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* 17. Would you be willing to support a special purpose bond to support an Assisted Living Facility and/or Senior Independent Living Housing?

Yes