This survey is part of a senior community needs assessment and gaps analysis for Sullivan County. Your participation in this survey will help ensure that the Sullivan County Office for the Aging understands the needs of seniors in the community and can better provide services and programs that will benefit Sullivan’s seniors.  The survey will take approximately 5-10 minutes of your time.

We thank you for taking the time to complete this survey! 

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* 1. What is your age range?(you must be 55 or older to complete the survey)

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* 2. What is your gender identity?

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* 3. What is your race or ethnicity?

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* 4. What is the primary language spoken at home?

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* 5. What is your zip code?

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* 6. What is your marital status?

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* 7. Are you currently working?

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* 8. What is your annual household income range (total all household members income together)?

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* 9. What is your housing status

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* 10. How many people (including yourself) are in your household?

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* 11. How many people in your household (including yourself) are over 55?

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* 12. Did you serve in the military? 

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* 13. Do you have difficulty with any of the following? (Please select all that apply)

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* 14. Select the activities you do now.(please select all that apply)

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* 15. How many times do you leave your home each week?

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* 16. Do you feel prepared if there were an emergency?

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* 17. In an emergency, is your home easily accessible?

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* 18. Do you have friends or family you see regularly that live nearby?

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* 19. Are you a caregiver to anyone or do you have dependents?

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* 20. If yes to question 19, to whom?

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* 21. Where do you hear about events and news going on in your community? (limit 70 words)

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* 22. What community resources, services, activities, or clubs do you use on a regular basis? (limit 70 words)

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* 23. Are there any community resources, services, activities, or clubs that you would like to use but are not aware of or have been unable to find?

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* 24. Do you have any needs that we did not ask about? If so, please describe. (limit 70 words)

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