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 County Government  >>   Departments  >>   Aging  >>   Needs and Concerns Feedback Form

Senior Citizen Needs and Concerns Survey Department Head Photo Aging
John A. Beale, Director
Your Opinion Is Important To Us

Dutchess County is conducting a study to determine the needs and concerns of our older residents. Please take a few minutes to complete the survey below. Click on the 'Submit' button to send it to the Dutchess County Office for the Aging. Your participation will help us to design and offer programs to meet your needs. Thank you for your assistance.

Please complete only if you are over age 60.

William R. Steinhaus
Dutchess County Executive

Please click inside the square box to check off whether each of the following items is a problem for you:

Problem
Understanding health insurance/Medicare
Keeping up with medical costs
Insufficient money for food, shelter, clothes
Affording energy and utilities
Managing household budgeting/bill paying
Household chores and maintenance
Feeling afraid or unsafe at home because you may fall or get injured
Feeling afraid or unsafe at home because of possible crime
Legal Affairs
Loneliness, isolation or depression
Disability or impaired mobility
Transportation - including for medical, shopping, recreation, etc.
Knowing where to obtain information about services and benefits
Taking care of another adult
Taking care of a grandchild
Taking care of personal needs - bathing, dressing, preparing meals
Conflicts with others such as family, neighbors, or creditors

Are there any problems important to you that are not on the list? If so, please specify:

(Max. No. of Characters: 2,000)

How would you rate your overall health:     Good  Fair  Poor

What is your Zip Code:    

Is Your Age: 60-74  75 or over

Ethnic Group:   White      African American/Black
Hispanic  Asian/Pacific Islander
American Indian/Alaskan Native
Other, (please specify):    

Is your household low income: Yes  No

Low Income defined as:

Household of 1 – no more than $16,245/year   Household of 5 – no more than $38,685/year
Household of 2 – no more than $21,855/year   Household of 6 – no more than $44,295/year
Household of 3 – no more than $27,465/year   Household of 7 – no more than $49,905/year
Household of 4 – no more than $33,075/year   Household of 8 – no more than $55,515/year
For households more than 8 members, add $3,740 for each additional member

Is there anything else you would like the Dutchess County Office for the Aging to know:

(Max. No. of Characters: 2,000)

Email: (required)

 
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Last Updated: 8/12/2010