Licking County Age Friendly Medium Survey
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1.
How important is it to you to remain in your home as you age?
(Required.)
Very important
Somewhat important
Not that important
Not at all important
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2.
How important is it to you to remain in Licking County as you age?
(Required.)
Very important
Somewhat important
Not that important
Not at all important
3.
Where you live, do you have access to the following?
Yes
No
Not Sure
Affordable home repair contractors who are trustworthy and do quality work
Yes
No
Not Sure
A low-cost or free home repair service
Yes
No
Not Sure
Seasonal services (lawn work or snow removal) which are affordable
Yes
No
Not Sure
Affordable housing options for older adults (such as active adult communities, assisted living and communities with meal plans or shared outdoor spaces)
Yes
No
Not Sure
Homes that are equipped with features such as no-step entry, wider doorways, first floor bedroom and bath, grab bars in bathrooms
Yes
No
Not Sure
Reliable and affordable internet service
Yes
No
Not Sure
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4.
Do you face any of the challenges listed below when traveling to an appointment, event, or community location? (Select all that apply)
(Required.)
I have no problems getting around
I do not drive
I cannot afford a car or car maintenance
I do not have others who are willing to take me
I have difficulties with parking due to mobility challenges
I have problems using senior transportation services
There are no senior transportation services in my community
I do not feel safe walking in my community
Other (please specify)
5.
Can you...
Yes
No
Sometimes
Get an appointment with your doctor when you need to?
Yes
No
Sometimes
Afford your medical bills?
Yes
No
Sometimes
Afford your over the counter medications?
Yes
No
Sometimes
Afford your prescriptions?
Yes
No
Sometimes
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6.
Do you experience any of the difficulties listed below when spending time outdoors or in public places (stores, parks, public buildings, etc.)? (Select all that apply)
(Required.)
Sidewalks are uneven/unsafe
Distance between places is too far
Pedestrian crossings are difficult to navigate
Difficulties with public toilets (too few, not accessible, unclean)
Too much noise or poor lighting
There is often no one to ask for help
There is often nowhere to sit and rest
Signs or printed materials are difficult to read (menus, etc.)
Aisles or counters are narrow or hard to navigate
Stairs and escalators are challenging to navigate
Other (please specify)
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7.
In general, are you able to find information on the services that you need?
(Required.)
All of the time
Most of the time
Sometimes
Rarely or Never
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8.
What is your employment status? (Select all that apply)
(Required.)
Employed full-time
Employed part-time
Self-employed
Retired and not looking for work
Retired and not seeking work
Unemployed and seeking work
Unable to work due to disability
Other (please specify)
9.
Do you agree with the following statements
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Older persons are generally treated wtih respect
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Older persons are valued in the community
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
People with disabilites are treated wtih respect
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
There are negative stereotypes about older adults
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
10.
Indicate how often you feel the way described:
Never
Rarely
Sometimes
Always
How often do you feel that you lack companionship?
Never
Rarely
Sometimes
Always
How often do you feel alone?
Never
Rarely
Sometimes
Always
How often do you feel that you are no longer close to anyone?
Never
Rarely
Sometimes
Always
How often do you feel left out?
Never
Rarely
Sometimes
Always
How often do you feel that no one really knows you well?
Never
Rarely
Sometimes
Always
How often do you feel that people are around you, but not with you?
Never
Rarely
Sometimes
Always
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11.
What is your age?
(Required.)
49 or less years
50-54 years
55-59 years
60-64 years
65-69 years
70-74 years
75-79 years
80-84 years
85-89 years
90-94 years
95-99 years
100 or more years
*
12.
What is your race and/or ethnicity? Please select all that apply.
(Required.)
American Indian/ Alaskan Native
Asian
Black/ African American
Native Hawaiian/ Pacific Islander
White
Middle Eastern
Hispanic
Self Describe:
*
13.
Do you rent or own?
(Required.)
Rent
Own
14.
What is your gender?
*
15.
What is your annual household income?
(Required.)
Under $10,000
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
$60,000-$74,999
$75,000-$99,999
$100,000-$149,999
$150,000 or higher
16.
What is your zip code?
