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Firehouse Flu Clinics

Needs Assessment Survey

The Chenango County Area Agency on Aging is asking for your help in assessing the needs for supportive services among people 60 years of age and over in Chenango County. Please take a few minutes to complete this survey form by checking the box that best reflects your need for assistance. When you have finished completing the survey, please press submit and it will be forwarded to our office.

Never
A Problem
Sometimes
A Problem
Frequently
A Problem
General Daily Activities
Housework/Cleaning
Grocery Shopping
Laundry
Transportation
Cooking/Preparing Meals
Managing Medications
Handling Finances/Paying Bills
Using The Telephone
Bathing/Showering
Daily Personal Hygiene
Dressing/Undressing
Help With Walking
Help With Transferring (e.g.: Moving from bed to chair)
Help Using the Bathroom
Help with Eating
Health Concerns
Having and Understanding Health Insurance
Finding Appropriate Medical Care
Nutrition
Eating a Nutritious Diet Daily
Finding Information About Special Dietary Requirements
Income
Having Enough Money for Food, Housing, Utilities, etc.
Finding or Paying for Legal Services
Safety
Feeling Anxious or Afraid When at Home
Feeling Anxious or Afraid When Away from Home
Socialization
Feeling Lonely or Depressed
Having Enough Social Activities

You do not have to give us your name, but please give us your age:  * Required

If you would like someone to contact you with information regarding services and benefits to seniors, please include your name and telephone number below:

Name:       Telephone:

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