Serving 18 Counties in Northwest Kansas

Northwest Kansas 
Area Agency on Aging

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Last Modified 07/22/04

Needs Survey

Sponsored by Northwest Kansas Area Agency on Aging

1.  How important are the following to you on a scale of 1 to 5, with 1 being the least important and 5 being the most important?  Please write the appropriate number beside each service

• Help with prescription drug purchase
• Health insurance counseling
• Exercise programs
• Healthy lifestyle information
• Meals at a nutrition site
• Home delivered meals
• Help with personal care/bathing
• Help with housework/cleaning
• Respite/temporary relief of caregivers
• Purchase of assistive bathroom items
• Purchase of products to assist with hearing, eating or sight
• Purchase of aids to help with mobility (wheelchair, cane, lift chair, etc.)
• Availability of community activities
• Provide family caregiver information
• Help with your oral health such as teeth, dentures, check-ups, etc.

2.  Is it difficult to find services for senior in your community?

• Yes
• No
• Don't Know

3.  I am familiar with services for senior offered by my Area Agency on Aging.

• Yes
• No
• Don't Know

4.  What county do you live in?

_________________________________

5.  Are you currently receiving help from any of the following?

• Spouse
• Home Health
• Family
• Friends
• Area Agency on Aging
• Other
• Church
• No, I don't receive any assistance

6.  My age is:

• 60-74
• 75+
• 90+

7.  I am:

• Male
• Female

Please complete the survey and return to:

NWKAAA, PO Box 610, Hays, KS  67601