THE 2004 CENTRAL MIDLANDS SURVEY

OF THE NEEDS OF CITIZENS OVER 55 YEARS OF AGE

 

Supporting our senior citizens is everyone’s business.  After all, we all hope to become senior citizens ourselves some day.  We at the Central Midlands Council of Governments are asking everyone to help us determine what the needs of senior citizens are.  No matter what your age, please fill out this survey and return it to us.  Thank you for your help.

 

PLEASE TELL US ABOUT YOURSELF BY FILLING IN THE BLANKS OR MAKING A CHECKMARK

 

 

I was born on (month)  (day)   (year)

 

I live in    County.

 

I went to school for years. 

 

I receive Aging services.

 

I care for a person over 55 years old who can’t care for themselves.

 

I do not receive services or care for someone who does, but I am interested in aging services and how they affect my community and me.

 

I would describe myself as:         I am:

 

Non-Hispanic White                Female

Non-Hispanic Black                 Male

Asian or Pacific Islander

Hispanic

 

PLEASE SELECT THE NUMBER THAT BEST DESCRIBES WHAT YOU THINK.

 

Definitely No

Probably No

Maybe Yes Maybe No

Probably Yes

Definitely Yes

1.  I believe there is a need for more chances for older people to spend time with other people. 

1

2

3

4

5

2.  I believe there is a need for more services for older people to help them stay in their homes as long as possible. 

1

2

3

4

5

3.  I believe the community should provide more ways for older people to keep their minds active.

1

2

3

4

5

4.  I believe that older people should have more chances to be active in the community. 

1

2

3

4

5

5.  I believe there is a need for more help for families who are trying to keep their older family members at home. 

1

2

3

4

5

6.  I believe there should be one place where older people and their families can get information about services and activities for older citizens.

1

2

3

4

5

7.  I believe there is a need for more transportation options for older people. 

1

2

3

4

5

 

PLEASE SELECT YOUR ANSWER TO THESE STATEMENTS                                   

                                           

1.  I know who to contact to find out about services for older people.

Yes

No

2.  I would be willing to volunteer to help in a program for older people.

Yes

No

3.  I am already helping in a program for older people. 

Yes

No

4.  I would like to see more in the media about aging. 

Yes

No

5.  I would like more information on keeping healthy. 

Yes

No

 

        PLEASE ANSWER IF 55 OR OLDER

 

        1.   The exercise I am most likely to take part in is

 

        2.  I would like to see more information available on these diseases:

        Other Comments You Would Like to Make

 

  Submit Survey

 

Return to: Sharon Seago, CMCOG, 236 Stoneridge Dr., Columbia, SC 29210

For questions call: 803-376-5390