Licking County Age Friendly Medium Survey

Question Title

* 1. How important is it to you to remain in your home as you age?

Very important

Somewhat important

Not that important

Not at all important

Question Title

* 2. How important is it to you to remain in Licking County as you age?

Very important

Somewhat important

Not that important

Not at all important

Question Title

* 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	Affordable home repair contractors who are trustworthy and do quality work Yes	Affordable home repair contractors who are trustworthy and do quality work No	Affordable home repair contractors who are trustworthy and do quality work Not Sure
A low-cost or free home repair service	A low-cost or free home repair service Yes	A low-cost or free home repair service No	A low-cost or free home repair service Not Sure
Seasonal services (lawn work or snow removal) which are affordable	Seasonal services (lawn work or snow removal) which are affordable Yes	Seasonal services (lawn work or snow removal) which are affordable No	Seasonal services (lawn work or snow removal) which are affordable Not Sure
Affordable housing options for older adults (such as active adult communities, assisted living and communities with meal plans or shared outdoor spaces)	Affordable housing options for older adults (such as active adult communities, assisted living and communities with meal plans or shared outdoor spaces) Yes	Affordable housing options for older adults (such as active adult communities, assisted living and communities with meal plans or shared outdoor spaces) No	Affordable housing options for older adults (such as active adult communities, assisted living and communities with meal plans or shared outdoor spaces) Not Sure
Homes that are equipped with features such as no-step entry, wider doorways, first floor bedroom and bath, grab bars in bathrooms	Homes that are equipped with features such as no-step entry, wider doorways, first floor bedroom and bath, grab bars in bathrooms Yes	Homes that are equipped with features such as no-step entry, wider doorways, first floor bedroom and bath, grab bars in bathrooms No	Homes that are equipped with features such as no-step entry, wider doorways, first floor bedroom and bath, grab bars in bathrooms Not Sure
Reliable and affordable internet service	Reliable and affordable internet service Yes	Reliable and affordable internet service No	Reliable and affordable internet service Not Sure

Question Title

* 4. Do you face any of the challenges listed below when traveling to an appointment, event, or community location? (Select all that apply)

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)

Question Title

* 5. Can you...

	Yes	No	Sometimes
Get an appointment with your doctor when you need to?	Get an appointment with your doctor when you need to? Yes	Get an appointment with your doctor when you need to? No	Get an appointment with your doctor when you need to? Sometimes
Afford your medical bills?	Afford your medical bills? Yes	Afford your medical bills? No	Afford your medical bills? Sometimes
Afford your over the counter medications?	Afford your over the counter medications? Yes	Afford your over the counter medications? No	Afford your over the counter medications? Sometimes
Afford your prescriptions?	Afford your prescriptions? Yes	Afford your prescriptions? No	Afford your prescriptions? Sometimes

Question Title

* 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)

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)

Question Title

* 7. In general, are you able to find information on the services that you need?

All of the time

Most of the time

Sometimes

Rarely or Never

Question Title

* 8. What is your employment status? (Select all that apply)

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)

Question Title

* 9. Do you agree with the following statements

	Strongly Agree	Agree	Not Sure	Disagree	Strongly Disagree
Older persons are generally treated wtih respect	Older persons are generally treated wtih respect Strongly Agree	Older persons are generally treated wtih respect Agree	Older persons are generally treated wtih respect Not Sure	Older persons are generally treated wtih respect Disagree	Older persons are generally treated wtih respect Strongly Disagree
Older persons are valued in the community	Older persons are valued in the community Strongly Agree	Older persons are valued in the community Agree	Older persons are valued in the community Not Sure	Older persons are valued in the community Disagree	Older persons are valued in the community Strongly Disagree
People with disabilites are treated wtih respect	People with disabilites are treated wtih respect Strongly Agree	People with disabilites are treated wtih respect Agree	People with disabilites are treated wtih respect Not Sure	People with disabilites are treated wtih respect Disagree	People with disabilites are treated wtih respect Strongly Disagree
There are negative stereotypes about older adults	There are negative stereotypes about older adults Strongly Agree	There are negative stereotypes about older adults Agree	There are negative stereotypes about older adults Not Sure	There are negative stereotypes about older adults Disagree	There are negative stereotypes about older adults Strongly Disagree

Question Title

* 10. Indicate how often you feel the way described:

	Never	Rarely	Sometimes	Always
How often do you feel that you lack companionship?	How often do you feel that you lack companionship? Never	How often do you feel that you lack companionship? Rarely	How often do you feel that you lack companionship? Sometimes	How often do you feel that you lack companionship? Always
How often do you feel alone?	How often do you feel alone? Never	How often do you feel alone? Rarely	How often do you feel alone? Sometimes	How often do you feel alone? Always
How often do you feel that you are no longer close to anyone?	How often do you feel that you are no longer close to anyone? Never	How often do you feel that you are no longer close to anyone? Rarely	How often do you feel that you are no longer close to anyone? Sometimes	How often do you feel that you are no longer close to anyone? Always
How often do you feel left out?	How often do you feel left out? Never	How often do you feel left out? Rarely	How often do you feel left out? Sometimes	How often do you feel left out? Always
How often do you feel that no one really knows you well?	How often do you feel that no one really knows you well? Never	How often do you feel that no one really knows you well? Rarely	How often do you feel that no one really knows you well? Sometimes	How often do you feel that no one really knows you well? Always
How often do you feel that people are around you, but not with you?	How often do you feel that people are around you, but not with you? Never	How often do you feel that people are around you, but not with you? Rarely	How often do you feel that people are around you, but not with you? Sometimes	How often do you feel that people are around you, but not with you? Always

Question Title

* 11. What is your age?

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

Question Title

* 12. What is your race and/or ethnicity? Please select all that apply.

American Indian/ Alaskan Native

Asian

Black/ African American

Native Hawaiian/ Pacific Islander

White

Middle Eastern

Hispanic

Self Describe:

Licking County Age Friendly Medium Survey

Question Title

* 1. How important is it to you to remain in your home as you age?

Question Title

* 2. How important is it to you to remain in Licking County as you age?

Question Title

* 3. Where you live, do you have access to the following?

Question Title

* 4. Do you face any of the challenges listed below when traveling to an appointment, event, or community location? (Select all that apply)

Question Title

* 5. Can you...

Question Title

* 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)

Question Title

* 7. In general, are you able to find information on the services that you need?

Question Title

* 8. What is your employment status? (Select all that apply)

Question Title

* 9. Do you agree with the following statements

Question Title

* 10. Indicate how often you feel the way described:

Question Title

* 11. What is your age?

Question Title

* 12. What is your race and/or ethnicity? Please select all that apply.

Question Title

* 13. Do you rent or own?

Question Title

* 14. What is your gender?

Question Title

* 15. What is your annual household income?

Question Title

* 16. What is your zip code?