THE SOMERSET COUNTY OFFICE ON AGING AREA PLAN SURVEY

Somerset County is conducting a survey to determine what services are important to older adults and their caregivers. Your response will help us devise priorities. Please answer the following questions so that we can gain a better understanding of the seniors living in Somerset County.

Mark the municipality to whom you pay your taxes or where you live:

Bedminster	Bernards	Bernardsville
Bound Brook	Branchburg	Bridgewater
Far Hills	Franklin	Green Brook
Hillsborough	Manville	Millstone
Montgomery	North Plainfield	Peapack/Gladstone
Raritan	Rocky Hill	Somerville
South Bound Brook	Warren	Watchung

Mark your age bracket:

60 -64

65 – 69

70-79

80 -84

85+

I have enrolled in Medicare-D		YES
I have enrolled in Medicare-D		NO

If “NO” , why not?

	My current coverage is as good as or better than the Medicare-D Plan
	I need assistance in selecting a plan.
	I would like a personalized report showing the best three plans for me. (Please complete personal information at the bottom of the survey.)

If you are a caregiver please indicate which of the following applies to you:

	I am a caregiver under age 60 providing care for an older adult (60+)
	I am a caregiver over age 60 providing care for:

	an older adult (60+)
	a disabled child
	my grandchild (full responsibility)

Mark your ethnic background:

White

African – American

Asian

Hispanic

Other

Mark your annual income:

	less than $15,000		$50,000 to $54,999
	$15,000 to $24,999		$55,000 to $59,999
	$25,000 to $34,999		$60,000 to $64,999
	$35,000 to $49,999		$65,000 and up

Mark your living arrangement:

	own my home		rent
	live with family		share housing with a friend

I may be interested in senior housing. I could afford:
	$600/month		$800/month		$1,100/month	Other month

If you had a question about services/programs for senior citizens who would you call first?

Do you belong to a church/synagogue/temple/?	YES	NO
Do you think your church/synagogue/temple would help you if you were in need?	YES	NO
Do you have trouble getting information or service because you do not speak English?	YES	NO

Please indicate ALL the services you feel your tax dollar should continue to support:

	Adult Day Care
	Adult Protective Services
	Information about services for older adults and referrals to services
	Support group for those who are caregivers for the elderly
	Services to give caregivers a break from day-to-day responsibilities
	Meals on Wheels (Home Delivered Meals)
	Senior Centers (places that offer activities, programs, services and lunch)
	Household Chore Services
	Handyman Services (volunteers who make small home repairs)
	Friendly Visitor (volunteers who visit with homebound persons weekly)
	Senior Employment training program (on the job training for older adults)
	Visiting Nurse Services
	Grocery shopping service (for those who are too frail to shop)
	Mental Health Services (assessment and counseling)
	Counseling on how to handle Medical Insurance questions and problems
	Quarterly Newsletter: about programs/services for older adults/caregivers
	Legal Services: advance directives living wills wills consultations
	Health promotion opportunities: education exercise screenings
	Transportation: Please mark all that apply
	Medical Appts.
	Grocery Shopping
	Recreation
	Mall Shopping
	YMCA/YWCA
	Senior Centers
	Volunteer Job
	Library
	Employment
	Other

Have you or a family member (age 60 or older) ever needed services to help you remain living in your home?		Yes		No
Do you presently use services in your home?		Yes		No

What services do you use?
What services do you need that are NOT available?

Why are these services unavailable to you?

Not Affordable

Services do not exist

Not eligible

Mark ALL the places you use to find out about services/opportunities for senior citizens:

	Television
	Radio
	Municipal Office
	Neighbor/Friend
	Newspaper
	Library
	Office on Aging
	Phone Book
	Internet
	Family Member
	Hospital
	Newsletter
	Church/Synagogue/Temple
	Senior Club
	Other

Is there an Office on Aging in Somerset County?
	Yes	No	Unsure
If dental care were offered at a reduced rate I would take advantage of it:
	Yes	No

Please complete if you need assistance with Medicare-D. Otherwise the section below is optional.

Name:
Address:
Town/City:
Zip Code:
Telephone Number:

Thank you for taking the time to complete your survey.