JP@Home Member Intake Form

All responses will be kept strictly confidential. Only aggregate data will be shared with Ethos staff and JP@Home Advisory Council members.

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* 1. First Name

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* 2. Last Name

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* 3. What is your email address?

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* 4. Have you ever served in any branch of the United States military, or not?

Yes, I have

No, I have not

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* 5.
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

Native American or Alaskan Native

Asian

Hawaiian or Pacific Islander

From Multiple Race

Did not answer

Other (please specify)

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* 6. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino Group?

I am not Spanish, Hispanic, or Latino

Mexican

Mexican-American

Chicano

Puerto Rican

Cuban

Cuban-American

Other Spanish, Hispanic or Latino Group

From multiple Spanish, Hispanic, Latino Groups

Prefer not to answer

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* 7. How many persons are included in your household?

5 or More

Prefer not to answer

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* 8. Which of the following best describes your current relationship status?

Married

Widowed

Divorced

Separated

In a Domestic Partnership or Civil Union

Single, But Cohabitating with a Significant Other

Single, But Cohabitating with a Non-Significant Other

Single, Never Married

Prefer not to answer

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* 9. Do you consider yourself to be:

Heterosexual

Homosexual

Bisexual

Transexual

None of the above

Prefer not to answer

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* 10. Home Ownership

Home Owner

Condo Owner

Renter

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* 11. Home Type

Single-Family Home

Multiple Family Home

Prefer not to answer

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* 12. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate Degree

Bachelor Degree

Graduate Degree

Doctorate Degree

Prefer not to answer

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* 13. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

Prefer not to answer

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* 14. Which of the following best describes your current or most recent occupation?

Legal Occupations

Production Occupations

Sales and Related Occupations

Community and Social Service Occupations

Computer and Mathematical Occupations

Food Preparation and Serving Related Occupations

Protective Service Occupations

Construction and Extraction Occupations

Arts, Design, Entertainment, Sports, and Media Occupations

Business and Financial Operations Occupations

Personal Care and Service Occupations

Education, Training, and Library Occupations

Building and Grounds Cleaning and Maintenance Occupations

Healthcare Practitioners and Technical Occupations

Healthcare Support Occupations

Transportation and Materials Moving Occupations

Management Occupations

Architecture and Engineering Occupations

Life, Physical, and Social Science Occupations

Office and Administrative Support Occupations

Prefer not answer

Other (please specify)

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* 15. What is your approximate average household income?

$0-$24,999

$25,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$124,999

$125,000-$149,999

$150,000-$174,999

$175,000-$199,999

$200,000 and up

prefer not to answer

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* 16. How often do you use the internet?

Daily

Weekly

Monthly

Yearly

Never

Prefer not to answer

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* 17. What is your most preferred communication method(s) from JP@Home? (Select all that apply)

Monthly Newsletter

Text Message

Postal Mail

Phone Call

In-person contact

Big Tent Discussion Board

Prefer not to answer

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* 18. What is the best time or day of the week for you to attend meetings of JP@Home members? (Select all that apply)

Mornings

Afternoons

Evenings

Weekdays

Weekends

Prefer not to answer

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* 19. What activities are you interested in? (Select all that apply)

Multi-cultural

Music

Theater

Art

Fitness & Excersise

Political & Social Causes

Support groups

Prefer not to answer

Other (please specify)

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* 20. Please tell us how important the following are to you as you age:

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* 21. How do you get around? (Check all that apply)

Walk

Bicycle

Public Transportation

Senior Shuttle

Taxis and Ride Hailing Services (Uber, Lyft, Etc.)

Car

Prefer not to answer

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* 22. In general, how would you rate your overall health?

Excellent

Very Good

Good

Fair

Poor

Did not answer

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* 23. Does your health status interfere with what you would like to do?

Yes

Did not answer

If yes, please explain:

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* 24. Emergency Contact

Name

Relationship

Phone#

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* 25. How did you hear about JP@Home? (Select all that apply)

Internet

Direct Mail

Friend or Family

Social Media

Community

Ethos Website

Did not answer

Other (please specify)

	High Priority	Very important	Somewhat Important	Not Important
Home Repair and Maintenance	Home Repair and Maintenance High Priority	Home Repair and Maintenance Very important	Home Repair and Maintenance Somewhat Important	Home Repair and Maintenance Not Important
Finding Information About Resources for Senior Citizens	Finding Information About Resources for Senior Citizens High Priority	Finding Information About Resources for Senior Citizens Very important	Finding Information About Resources for Senior Citizens Somewhat Important	Finding Information About Resources for Senior Citizens Not Important
Finding Information About Long-Term Care Services and Insurance	Finding Information About Long-Term Care Services and Insurance High Priority	Finding Information About Long-Term Care Services and Insurance Very important	Finding Information About Long-Term Care Services and Insurance Somewhat Important	Finding Information About Long-Term Care Services and Insurance Not Important
Organized Trips (e.g., Trips to Movies, Museums, Plays, Casinos, Historical Sites)	Organized Trips (e.g., Trips to Movies, Museums, Plays, Casinos, Historical Sites) High Priority	Organized Trips (e.g., Trips to Movies, Museums, Plays, Casinos, Historical Sites) Very important	Organized Trips (e.g., Trips to Movies, Museums, Plays, Casinos, Historical Sites) Somewhat Important	Organized Trips (e.g., Trips to Movies, Museums, Plays, Casinos, Historical Sites) Not Important
Finding Information About Community Safety	Finding Information About Community Safety High Priority	Finding Information About Community Safety Very important	Finding Information About Community Safety Somewhat Important	Finding Information About Community Safety Not Important
Transportation to Shopping, Religious Services, Visiting Friends, Etc.	Transportation to Shopping, Religious Services, Visiting Friends, Etc. High Priority	Transportation to Shopping, Religious Services, Visiting Friends, Etc. Very important	Transportation to Shopping, Religious Services, Visiting Friends, Etc. Somewhat Important	Transportation to Shopping, Religious Services, Visiting Friends, Etc. Not Important
Finding and Coordinating Services, Visiting Friends, Etc.	Finding and Coordinating Services, Visiting Friends, Etc. High Priority	Finding and Coordinating Services, Visiting Friends, Etc. Very important	Finding and Coordinating Services, Visiting Friends, Etc. Somewhat Important	Finding and Coordinating Services, Visiting Friends, Etc. Not Important
Keeping the House Clean	Keeping the House Clean High Priority	Keeping the House Clean Very important	Keeping the House Clean Somewhat Important	Keeping the House Clean Not Important
Social Opportunities (e.g., Book Clubs, Bridge Games, Sewing Clubs, Social Events)	Social Opportunities (e.g., Book Clubs, Bridge Games, Sewing Clubs, Social Events) High Priority	Social Opportunities (e.g., Book Clubs, Bridge Games, Sewing Clubs, Social Events) Very important	Social Opportunities (e.g., Book Clubs, Bridge Games, Sewing Clubs, Social Events) Somewhat Important	Social Opportunities (e.g., Book Clubs, Bridge Games, Sewing Clubs, Social Events) Not Important
Opportunities for Exercise (e.g., Walking Clubs, Exercise Classes, Water Aerobics)	Opportunities for Exercise (e.g., Walking Clubs, Exercise Classes, Water Aerobics) High Priority	Opportunities for Exercise (e.g., Walking Clubs, Exercise Classes, Water Aerobics) Very important	Opportunities for Exercise (e.g., Walking Clubs, Exercise Classes, Water Aerobics) Somewhat Important	Opportunities for Exercise (e.g., Walking Clubs, Exercise Classes, Water Aerobics) Not Important
Installing Home Safety Equipment	Installing Home Safety Equipment High Priority	Installing Home Safety Equipment Very important	Installing Home Safety Equipment Somewhat Important	Installing Home Safety Equipment Not Important
Finding Someone to Check my Home for Things that Might Cause Me to Fall	Finding Someone to Check my Home for Things that Might Cause Me to Fall High Priority	Finding Someone to Check my Home for Things that Might Cause Me to Fall Very important	Finding Someone to Check my Home for Things that Might Cause Me to Fall Somewhat Important	Finding Someone to Check my Home for Things that Might Cause Me to Fall Not Important
Keeping Track of Money and Bills	Keeping Track of Money and Bills High Priority	Keeping Track of Money and Bills Very important	Keeping Track of Money and Bills Somewhat Important	Keeping Track of Money and Bills Not Important
Prefer not to answer	Prefer not to answer High Priority	Prefer not to answer Very important	Prefer not to answer Somewhat Important	Prefer not to answer Not Important

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. What is your email address?

Question Title

* 4. Have you ever served in any branch of the United States military, or not?

Question Title

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

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* 6. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino Group?

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* 7. How many persons are included in your household?

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* 8. Which of the following best describes your current relationship status?

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* 9. Do you consider yourself to be:

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* 10. Home Ownership

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* 11. Home Type

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* 12. What is the highest level of school you have completed or the highest degree you have received?

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* 13. Which of the following categories best describes your employment status?

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* 14. Which of the following best describes your current or most recent occupation?

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* 15. What is your approximate average household income?

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* 16. How often do you use the internet?

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* 17. What is your most preferred communication method(s) from JP@Home? (Select all that apply)

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* 18. What is the best time or day of the week for you to attend meetings of JP@Home members? (Select all that apply)

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* 19. What activities are you interested in? (Select all that apply)

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* 20. Please tell us how important the following are to you as you age:

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* 21. How do you get around? (Check all that apply)

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* 22. In general, how would you rate your overall health?

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* 23. Does your health status interfere with what you would like to do?

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* 24. Emergency Contact

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* 25. How did you hear about JP@Home? (Select all that apply)

* 5.
Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, or some other race?