1.
Which of the following needs concern you now or could in the next five years?

Check any and all that apply.
2.
Please check the 3 concerns that are most important to you.
3.
Which of the following are safety concerns now or could be in the next five years?

4.
I am connected or involved with the following in my community:
Select any or all that apply.
5.

What keeps you from using some services for seniors?

Choose any or all that apply.
6.
Within the last year how often have you attended a senior meal or CHAMPSS site?

Regarding attendance at any of the 6 senior meal sites OR CHAMPSS meals at the 6 participating Hy-Vee dining centers.
7.
I have the following health care coverage:

Choose any or all that apply.
8.
Within the past year, I consider my overall health to have been:

9.

I have problems accessing the following services because of cost. 

Choose any or all that apply.
10.
I have problems accessing the following services because of availability.
Choose any or all that apply.
11.
I have problems accessing the following services because of transportation.
Choose any or all that apply.
12.
During the past year, I have received health care at:

Choose any or all that apply.
13.
I provide non-paid care for a senior adult:

14.
I am able to live in my home because I receive help from:

Choose any or all that apply.
15.
I provide unpaid care or support for a dependent minor or disabled child:

Choose any or all that apply.
16.
I contact my political leaders...
17.
18.
19.
My age group is

20.
Any additional needs, comments, or concerns: