Senior Community Needs Survey – Storm Recovery Relief

Senior Community Needs Survey – Storm Recovery Relief

The purpose of this survey is to hear directly from the senior community about the household, personal care, cleaning, and recovery resources they need most. Your responses will help our collaborating chapters and community partners focus our efforts on the needs identified directly by the community.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
About You
What is your age range?
How many people live in your household?
Household Needs
Which household essentials would be most helpful to you? (Select all that apply)
Other
Personal Care
Which personal care items would be most helpful to you? (Select all that apply)
Other
Cleaning & Recovery
Which cleaning supplies would be most helpful to you? (Select all that apply)

Other
Other
Your Top Needs
What are the three items you need most right now?
Is there something you need that is often overlooked in donation drives?
Is there anything else you would like us to know about the needs of older adults recovering from the storms?
Service Assistance

Our goal is to provide practical, hands-on assistance that helps make recovery a little easier. Please let us know if you would benefit from having your Senior Support Kit delivered during Get in Action Day of Service on October 10th. Your responses will help us coordinate volunteers and focus our service where it is needed most.
Would delivery of your Senior Support Kit be helpful?
Do you need cleanup services at this time?
What type of cleanup assistance would be most helpful?

Other
Other
Which area of your home or property needs the most assistance?

Other
Other
Approximately how much assistance do you believe you need?
If you request delivery or cleanup assistance, may a member of our service team contact you to coordinate your service?
Do you currently have a health or medical need that requires assistance or attention?
If yes, what type of assistance or resource would be helpful?
Other
Thank you for sharing your needs with us. Your responses will help us prepare resources based on what older adults in our community say they need most.
Get in Action with Social Action

Your Needs. Our Action. Our Community.Tell us what you need, and together, we’ll Make It Happen and Get in Action
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Senior Community Needs Survey – Storm Recovery Relief

About You

Household Needs

Personal Care

Cleaning & Recovery

Your Top Needs

Service Assistance

Get in Action with Social Action