2025-29 AAA Community Assessment Survey

2025-29 AAA Community Assessment Survey

CAPECO Area Agency on Aging - Area Plan
As a valued member or our Northeastern Oregon community, CAPECO welcomes you to assist us in learning more from our local residents and community partners, to better serve you.

Thank you for your time and participation!
Date*

MonthDayYear
Date
1. What county do you live in? (Select one.)*

GilliamHood RiverMorrowShermanUmatillaWascoWheelerOther
2. What is your age in years? (Select one.)*

a. 90+b. 85-89c. 80-84d. 75-79e. 70-74f. 65-69g. 60-64h. 55-59i. 50-54j. 49 or younger
3. What is your primary language?*

EnglishSpanishOther
4. Please describe your gender.*

a. Maleb. Femalec. Non-Binaryd. Decline to state.Other
5. Do you identify as LGBTQ? (Choose one.)*

a. Yesb. No
6. Which of the following describes your racial or ethnic identity? (Please choose all that apply.)*

a. Hispanic or Latinob. American Indian or Alaskan Nativec. Middle Eastern and North Africand. Black and African Americane. Asianf. Native Hawaiian and Pacific Islanderg. Whiteh. Multiplei. Unknown/Decline to stateOther
7. Do you have a disability?*

a. Yesb. No
8. Are you a caregiver for an adult age 60 or over or for a person with Alzheimer's disease or other dementia of any age?*

a. Yesb. No
9. Are you a parent or older relative caregiver, age 55 or older, who lives with, and is the primary caregiver for an individual with disabilities, between the ages of 18 and 59?*

a. Yesb. No
10. Are you an older relative caregiver (other than a parent), age 55 or older, who lives with, and is the primary caregiver for a child aged 18 or younger?*

a. Yesb. No
11. Does anyone in your household experience confusion or memory loss that significantly impacts daily life?*

a. Yesb. No
12. Do you feel lonely or isolated? (on a 1-5 scale - 1=Never, 5=Always)*
Enter a number from 1 to 5 to indicate your feelings of loneliness.
13. How often do you use the Internet? (on a 1-5 scale - 1=Never, 5=12+ Hours per Day)*
Enter a number from 1 to 5 to indicate your level of regular Internet usage.
14. How comfortable are you using technology (cell phone, computer, tablet, Roku/streaming service, etc.)? (on a 1-5 scale - 1=Not at all comfortable, 5=Completely comfortable*
Enter a number from 1 to 5 to indicate your level of comfort using technology.
15. If you do experience challenges with using technology, please describe your challenges in any way you choose.
16. Where do you get most of your information? (Choose one.)*

a. TVb. Social Media/Internetc. Newspaperd. Radioe. Family/Friendsf. MailOther
17. What is your preferred method of communication? (Choose one.)*

a. Phoneb. Emailc. Face-to-Faced. Texte. Mailf. Social MediaOther
18. Do you know about the Aging and Disability Resource Connection (ADRC) and are you able to use it to get information about the resources you need or want? (Choose one.)*

a. Yesb. No
19. How likely do you think it is that you will need the following services within the next five years? Enter a number - 1 to 3 - in each box (1=Very likely; 2=Somewhat likely; 3=Not likely)*
20. Do you have enough money to buy nutritious food? (choose yes or no)*

YesNo
21. Can you afford to pay for medical care, including appointments and medications? (choose yes or no)*

YesNo
22. Do you have enough money to pay for housing? (choose yes or no)*

YesNo
23. Do you have enough money to pay for utilities and other bills? (choose yes or no)*

YesNo
24. Do you feel safe in your home (has someone hurt or threatened to hurt you; has anyone taken or threatened to take your possessions or medications)? (choose yes or no)*

YesNo
25. Would you like to speak to a Case Manager about services available to seniors in your area?*

YesNo
If you answered yes to the question above (#25) and would like us to reach out to you, please leave us your contact information for follow-up:
OR you may also call the Aging and Disability Resource Connection of Oregon phone line at: 541-705-5434 OR 855-673-2372 (toll-free)
26. Are you currently receiving or have you previously received services through CAPECO?*

YesNo
27. If you answered "Yes" to the question above, how would you rate your overall experience and satisfaction with the CAPECO services you received? (on a 1-10 scale - 1=Poor, 10=Excellent
Enter a number from 1 to 10 to indicate your overall CAPECO client satisfaction level.
28. Is there anything else you would like us to know about? If so, please write your comments below:
This completes the survey. Please click SUBMIT, below. Thank you for your time and input.
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