THE EASTERN AREA AGENCY ON AGING
AREA PLAN SURVEY


The Eastern Area Agency on Aging is conducting a survey to determine what services are important to older adults and their caregivers. Your response will help us plan priorities. Please answer the following questions so that we can gain a better understanding of the needs of older adults living in our region. A pre-paid return envelope is included with this survey and we hope you can return it by April 15, 2008. We greatly appreciate your help with this survey.
Thank you very much.

Noëlle Merrill
Executive Director

Survey

Which county do you curently live in:

What Is you age range:

Have you enrolled in Medicare:

If No, why not? (check one)

My current coverage is as good as or better than the Medicare-D Plan
I need assistance in selecting a plan.

I need help finding a prescription plan; please contact me:

Name:
Address
City, State, Zip
Telephone:
Best Time:

 

If you are a caregiver please indicate which of the following applies to you:

If you are a caregiver please indicate which of the following applies to you:
I am a caregiver over age 60 providing care for:
 

What is yout ethnic background:

What is your annual income:

What is your living arrangement:

I may be interested in senior housing, I could afford:

                        If other :

If you had a question about services/programs for senior citizens who would you call first?

Do you belong to a church:
 Do you think your church/synagogue/temple would help you if you were in need?

Please indicate the TOP FIVE (5) issues that effect your life this year:

What are your transportation needs - Please mark all that apply:

Have you or a family member (age 60 or older) ever needed services to help you remain living in your home?:

Do you presently use services in your home?:


 What services do you use?
What services do you need that are NOT available?

Why are these services unavailable to you?:

Mark  ALL the places you use to find out about services/opportunities for senior citizens: