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Office on Aging Needs Assessment Survey

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Please correct the fields below:

Please correct the field(s) marked in red below:

Please complete the survey below. This information will allow us to better serve you. If you wish to complete this via a paper copy, please download this and return it to Mercer County Office on Aging/ADRC, 640 S. Broad St., P.O. Box 8068, Trenton, NJ 08650-0068 or fax your response to 609-588-0005.

1. How difficult is it for you - or the person/people to whom you provide care - to do the following:

	No help needed	Getting all the help needed	Getting some of the help needed	Not getting any of the help needed	Don't know if help is needed
Find information on available services	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Purchase enough food to eat	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Shop for groceries or other needed items	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Find transportation when needed	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Care for personal needs - bathing, dressing, using the toilet, etc.	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Clean your home, prepare meals, and do laundry	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Take care of simple tasks like changing lightbulbs or batteries, small repairs	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Spend time with family and friends in person	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Stay connected with people by phone, video, or through the internet	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Help with lawn care	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Obtain medical care	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:
Obtain legal advice or assistance	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:	1. How difficult is it for you - or the person/people to whom you provide care - to do the following:

2. If you are NOT able to get the help that you or a loved one needs, why is that? (Check all that apply.)

2. If you are NOT able to get the help that you or a loved one needs, why is that? (Check all that apply.)

Services are too expensive.

The amount of care I already receive is not enough.

The needs are not covered by insurance or the provider.

There is a waiting list for the help needed.

I don't know where to find the help needed.

Other If other, type text here.

3. Are you providing care for a family member, friend, or neighbor?

Yes

No (if you answered "No," please skip to #7.)

4. If you are a family caregiver, would you like additional help getting in-home care to meet the needs of your loved one(s)?

Yes

5. Are you participating in any caregiver support groups?

Yes

If you answered "Yes" to the above question, please indicate which one(s). if you answered "No," please tell us why you are not participating in any caregiver support groups.

6. What types of other services would help you care for others or take care of your needs better?

7. Have you tried to find professional help when feelings of loneliness, grief, isolation, or hopelessness make it too hard for you to take care of yourself or others?

Yes, and it helped.

Yes, but I still need help.

Yes, but it is too expensive.

Yes, but I couldn't get there.

No, I haven't needed to.

No, I don't know where to look.

8. Do you feel you or a loved one might have been physically, emotionally, financially, or sexually mistreated?

Yes

If you answered "Yes" to the above question, would you like to be contacted to find help? (Please provide your name and phone number.)

9. What services do you think should be provided or funded by the Mercer County Office on Aging for people over age 60, younger adults with disabilities, and their family caregivers?

10. What are your top three concerns as you age or your loved one ages?

If you are assisting someone to complete this survey, please answer the following for them:

I am a (please check all that apply):

Senior (age 60 or older)

Family member

Caregiver

Professional/senior service provider

Veteran

Member of the LGTBQ+ community

I am caring for (please check all that apply):

A spouse

A grandchild

A partner or significant other

An adult child with a disability

A friend or neighbor

Another family member

I identify as:

Gender

I identify as: Gender

Female

Male

Other

I identify as:

Race

I identify as: Race

White/Non-Hispanic

Black or African American

White Hispanic

American Indian/Native American

Asian

Native Hawaiian or Pacific Islander

Two or more races

Other

I identify as:

Ethnicity

I identify as: Ethnicity

Hispanic or Latino

Not Hispanic or Latino

My age is:

Under 60

60-64

65-74

75-84

85-94

95+

Please provide any additional comments, suggestions, or ideas for the Mercer County Office on Aging.

Where do you look for information about services and programs for adults over age 60? (Please select as many as apply.)

The Mercer County Office on Aging welcomes your calls, concerns, and questions. Please call 609-989-6661 to speak with a member of our staff.

To receive a copy of your submission, please fill out your email address below and submit.
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