17th ACL National Survey of Older Americans Act Participants

This is the U.S. Department of Health and Human Services’ Administration for Community 

Living (ACL) National Survey of Older Americans Act Participants (NSOAAP) for people 

receiving <transportation>1 services. More information about NSOAAP can be found at

www.AoAsurvey.org.

This survey helps ACL know if the Older Americans Act (OAA) transportation services that you 

and others have received have been helpful. This survey is also conducted to better understand 

the needs of the individuals who use the <transportation> services. 

This survey will take about 30 minutes to complete. Your participation is voluntary and very 

important to the success of this study. Reports and studies resulting from this survey will 

summarize information provided by participants and will not associate responses with a specific 

individual. Your eligibility for services will not be affected by your decision to participate or by 

any answers you give. 

It is very important that the questions in this booklet be answered by the person addressed in 

the letter. That person may receive assistance filling out the questionnaire, if needed, but the 

questions should be answered from his or her point of view.

You may skip any question that you do not want to answer, but we would really appreciate your 

answering all the questions you can.

MAILING INSTRUCTIONS: Please return your completed questionnaire in the pre-addressed 

postage paid envelope. If you have any questions about the questionnaire, please feel free to 

call us at 1-855-519-7052.

1 The service stated here will vary depending on OAA program of interest, per NSOAAP 

respondent. The services are: Home-delivered meals, Congregate meals, Homemaker, Case 

Management, and Transportation. Clients who receive more than one service will only take the 

survey for one service, for which they were randomly selected.

An agency may not conduct or sponsor, and a person is not required to respond to a collection 

of information, unless it displays a currently valid OMB control number. The OMB control 

number for this information collection is 0985-0023 and the expiration date is 5/31/24. Public 

reporting burden for this information collection is estimated to average 30 minutes per response. 

Send comments regarding this burden estimate or any other aspect of this collection of 

information, including suggestions for reducing this burden to the Administration for Community 

Living, Washington, DC 20201 Attn: Dr. Kristen Robinson, (888) 204-0271.

1 
A. Home-Delivered Meals Services* *This section is only for people receiving home-delivered meals services. 

The first set of questions is about the food services you receive from a meals provider

(“provider”) through your Area Agency on Aging (AAA).

A1. When was the last time you received food from the meals program such as a homedelivered meal, grocery/food delivery, or food that you picked up? This does not include a sitdown meal at the senior center or other group setting.

a. Today or yesterday

b. More than 1 day to 1 week ago

c. More than 1 week to 1 month ago

d. More than 1 month ago

e. Only got 1 meal

f. Over 1 year ago

g. Never received

(If your response is e, f, or g): 

THANK YOU. The focus of this survey is on people who have used the home-delivered meals 

service within the past year. If it has been more than one year since you received a home 

delivered meal or food or you only received it one time, please stop here and go to mailing 

information on page 26. Thank you for your interest in participating.

A2. How long have you been participating in the meals program?

a. 6 months or less

b. More than 6 months, but less than 1 year

c. At least 1 year, but less than 2 years

d. 2 to 5 years

e. More than 5 years

A3. In the past 12 months, how have you been receiving meals or food from the provider?

Please mark all that apply.

a. Meals delivered to your home

b. Groceries or food boxes delivered to your home

c. A food box with random ingredients

f. A food box containing food items to make meals; that may come with instructions

d. Grab-n-go, such as pick-up, carry-out, or drive-through

g. A sit-down meal at a senior center or other place

A4. In the past 12 months, which type of food or meal do you most often receive from the 

provider?

a. A hot meal

b. A cold meal like a sandwich or submarine

c. A food box, groceries, or shelf-stable packaged food

d. A frozen meal that needs to be heated up or microwaved

2 
A5. If you marked that you have meals, groceries, or food boxes delivered to your home, has 

knowing that you will receive regular visits by the home-delivered meals volunteer or driver 

made you feel safer at home because they can check in on you?

a. Yes

b. No

A6. If you marked that you have meals, groceries, or food boxes delivered to your home, do the 

home-delivered meals or food arrive when expected?

a. Always

b. Usually

c. Sometimes

d. Seldom

e. Never

A7. Other than the person who delivers the meals, how many times a week do you have 

personal contact (face-to-face) with a friend, family member, or other visitor?

a. None

b. One time

c. Two times

d. Three times

e. Four times

f. Five times

g. Six times

h. Every day

A8. How many days each week do you receive home-delivered meals or pick up meals?

_____________ (0 to 7 Days)

A9. How many meals do you get on the days that you receive home-delivered meals?

____________ Number of meals

A10. On the days you receive a home-delivered meal or pick up a meal, what portion of all the 

foods that you eat in a day does the meal represent?

a. Less than one-third

b. Between one-third and one-half

c. About one-half

d. More than one-half

e. Other

A11. How would you rate the meals program overall?

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

3 
A12. Think about all the foods that you receive from the meals program. How often are you 

satisfied with the way the food tastes?

a. Always

b. Usually

c. Sometimes

d. Seldom

e. Never

A13. Think about all the foods that you receive from the meals program. How often are you 

satisfied with the variety of the foods?

a. Always

b. Usually

c. Sometimes

d. Seldom

e. Never

A14. Would you recommend this service to a friend?

a. Yes

b. No

A15. Do you eat healthier foods as a result of the meals program?

a. Yes

b. No

A16. Does eating meals or food from the meals program improve your health?

a. Yes

b. No

A17. Do home-delivered meals or food help you to continue to live independently? By continue 

to live independently, we mean you are able to stay living where you desire such as in your 

current community and home.

a. Yes

b. No

4 
A. Congregate Meals Services* *This section is only for people receiving congregate meals services. 

The first set of questions is about the food services you receive from a meals provider

(“provider”) through your Area Agency on Aging (AAA).

A1. When was the last time you received a meal or other food from the meals program?

This includes a sit-down meal at the senior center or other group setting.

a. Today or yesterday

b. More than 1 day to 1 week ago

c. More than 1 week to 1 month ago

d. More than 1 month ago

e. Only got 1 meal

f. Over 1 year ago

g. Never received

(If your response is e, f, or g): 

THANK YOU. The focus of this survey is on people who had a meal in a group setting (called

“congregate meals”) or used the grab-n-go service (such as pick-up, carry-out, or drive-through)

within the past year. If it has been more than one year since you received these type of food

services or you only received it one time, please stop here and go to mailing information on 

page 26. Thank you for your interest in participating.

A2. How long have you been participating in the meals program?

a. 6 months or less

b. More than 6 months, but less than 1 year

c. At least 1 year, but less than 2 years

d. 2 to 5 years

e. More than 5 years

A3. In the past 12 months, how have you been receiving meals or food from the provider? 

Please mark all that apply.

a. Grab-n-go, such as pick-up, carry-out, or drive-through

b. Meals delivered to your home

c. Groceries or food boxes delivered to your home

d. A food box with random ingredients

e. A food box containing food items to make meals; that may come with instructions

f. A sit-down meal at a senior center or other place

A4. In the past 12 months, which type of food or meal do you most often receive from the 

provider?

a. A hot meal

b. A cold meal like a sandwich or submarine

c. A food box, groceries, or shelf-stable packaged food

d. A frozen meal that needs to be heated up or microwaved

A5. How many days each week do you eat at the senior center or other group setting 

associated with the meals program?

_____________ (0 to 7 Days)

5 
A6 On the days you eat a congregate meal, what portion of all the foods that you eat in a day 

does the meal represent?

a. Less than one-third

b. Between one-third and one-half

c. About one-half

d. More than one-half

e. Other

A7. How would you rate the meals program overall?

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

A8. Think about all the foods that you receive from the meals program. How often are you 

satisfied with the way the food tastes?

a. Always

b. Usually

c. Sometimes

d. Seldom

e. Never

A9. Think about all the foods that you receive from the meals program. How often are you 

satisfied with the variety of the foods?

a. Always

b. Usually

c. Sometimes

d. Seldom

e. Never

A10. Would you recommend this service to a friend?

a. Yes

b. No

A11. Do you eat healthier foods as a result of the meals program?

a. Yes

b. No

A12. Does eating at the senior center or other group setting associated with the meals program

improve your health?

a. Yes

b. No

A13. Does the meals program help you to continue to live independently? By continue to live 

independently, we mean you are able to stay living where you desire such as in your current 

community and home.

a. Yes

b. No

6 
A14. As a result of receiving meals, do you see your friends more often?

a. Yes

b. No

7 
A. Case Management Service* *This section is only for people receiving case management services. 

The first set of questions is about the case management service you receive from a case 

manager through your Area Agency on Aging (AAA). Your case manager is the person who sets 

up in-home services, such as homemaker or personal care services for you. The case manager 

also calls to check on how you are doing, or how you like your services.

A1. When was the last time you received case management service?

a. Today or yesterday

b. More than 1 day to 1 week ago

c. More than 1 week to 1 month ago

d. More than 1 month ago

e. Only got 1 meal

f. Over 1 year ago

g. Never received

(If your response is e, f, or g): 

THANK YOU. The focus of this survey is on people who used the case management service 

within the past year. If it has been more than one year since you received assistance from a 

case manager or you only received assistance one time, please stop here and go to mailing 

information on page 26. Thank you for your interest in participating.

A2. How long have you been receiving service from your case manager?

a. 6 months or less

b. More than 6 months, but less than 1 year

c. At least 1 year, but less than 2 years

d. 2 to 5 years

e. More than 5 years

A3. Do you know how to contact your case manager when you need to?

a. Yes

b. No

A4. Does your case manager return your phone calls in a timely manner?

a. Yes

b. No

A5. Does your case manager explain your services in a way that you can understand?

a. Yes

b. No

A6. Do you and your case manager work together to decide what services you need?

a. Yes

b. No

A7. Does your case manager treat you with respect?

a. Yes

b. No

8 
A8. Does your case manager involve you in discussing and planning for your services? 

a. Yes

b. No

A9. Does your case manager do a good job setting up care for you?

a. Yes

b. No

A10. Does your case manager help you get services that you did not have before?

a. Yes

b. No

A11. Has your situation improved because of the services your case manager arranges?

a. Yes

b. No

A12. Did your case manager develop a care plan for the service you need? A care plan is a 

document that contains information about who saw you, your needs, what kinds of services you

receive and how you are doing once you receive the services.

a. Yes

b. No (go to A14)

A13. Did you get a copy of the plan?

a. Yes

b. No

A14. Are you able to select the services you receive?

a. Yes

b. No

A15. Are you able to select your service provider?

a. Yes

b. No

A16. How would you rate the overall quality of the case management service you receive?

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

A17. Does the case management service help you to continue to live independently? By 

continue to live independently, we mean you are able to stay living where you desire such as in 

your current community and home.

a. Yes

b. No

A18. As a result of receiving the case management service, do you have a better idea of where 

to get information about other services?

a. Yes

b. No

9 
A. Transportation Services* *This section is only for people receiving transportation services.

The first set of questions is about the transportation service you receive from the transportation 

company (“provider”) through your Area Agency on Aging (AAA). Transportation is a bus or 

other vehicle that picks people up and takes them places such as to the doctor, the senior 

center, or shopping, and includes recreational trips.

A1. When was the last time you used this service?

a. Today or yesterday

b. More than 1 day to 1 week ago

c. More than 1 week to 1 month ago

d. More than 1 month ago

e. Only used it once (includes getting help for a short time, e.g., after a hospital stay)

f. Over 1 year ago

g. Never received

(If your response is e, f, or g): 

THANK YOU. The focus of this survey is on people who have used the transportation service 

within the past year. If it has been more than one year since you used the transportation service 

or you only received it one time, please stop here and go to mailing information on page 26.

Thank you for your interest in participating.

A2. About how long ago did you start using this transportation service?

a. 6 months or less

b. More than 6 months, but less than 1 year

c. At least 1 year, but less than 2 years

d. 2 to 5 years

e. More than 5 years

A3. How often do you use the transportation service?

a. 5 or more times per week

b. 2 to 4 times per week

c. Once per week

d. 1-3 times per month

e. Less than once per month

A4. About how many local one-way trips per month do you make using this service? For 

example, if you go to the grocery store and then come back using this service, that counts as 2 

one-way trips.

_______ Number of trips

A5. In an average month, would you say you rely on this transportation service for:

a. Just a few of your local trips

b. About 1/4 of all your local trips

c. About 1/2 of all your local trips

d. About 3/4 of all your local trips

e. Nearly all of your local trips

10
A6. When receiving a ride from your transportation provider, where do you get on the vehicle?

a. The driver comes to my door

b. The vehicle stops in front of my home

c. The vehicle stops down the block

d. I have to walk several blocks to get

e. I get on the vehicle at the senior center

A7. How frequently do these statements apply to your overall experience with your Area Agency 

on Aging (AAA) and transportation provider? 

Please mark one of these five responses for each item: Always, Usually, Sometimes, Seldom, 

or Never.

a. The drivers are polite.

b. The drivers pick me up when they are supposed to.

c. The vehicles are easy to get into and out of.

d. The vehicles are comfortable.

e. I arrive at my destination on time.

f. I get rides at the times and on the days I need them.

A8. Do you need help getting into and out of your home?

a. Yes

b. No (go to A9)

A8a.Does the driver or aide help you get into and out of your home?

a. Yes

b. No 

A9. Do you need help getting into or out of the van or bus?

a. Yes

b. No (go to A10)

A9a. Does the driver or aide help you get into or out of the van or bus?

a. Yes

b. No 

A10. Do you use the transportation service to get to...? 

Please mark all that apply.

a. Doctors and health care providers

b. Shopping

c. Volunteer activities

d. The Senior center

e. A location to pick up or have a meal

f. Friends, neighbors, and relatives

g. Social events and recreation activities

h. Religious services

11
A11. How would you rate the transportation service that you received?

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

A12. Do you get around more than you did before you had this service? 

a. Yes

b. No

A13. Would you recommend this transportation service to a friend?

a. Yes

b. No

A14. Do the services you receive help you to continue to live independently? By continue to live 

independently, we mean you are able to stay living where you desire such as in your current 

community and home.

a. Yes

b. No

A15. Is there a car or personal motor vehicle in working condition in your household?

a. Yes

b. No (go to B1)

A15a. Do you ever drive that car or personal motor vehicle?

a. Yes

b. No

12
A. Homemaker Services* *This section is only for people receiving homemaker services. 

The first set of questions is about the homemaker or housekeeping service you receive through 

your Area Agency on Aging (AAA). These services include doing light housework, assistance 

with preparing meals, managing money, using the telephone, shopping for personal items, and 

delivery of groceries, prescriptions, or other supplies to your home.

A1. When was the last time you received the homemaker service?

a. Today or yesterday

b. More than 1 day to 1 week ago

c. More than 1 week to 1 month ago

d. More than 1 month ago

e. Only got 1 meal

f. Over 1 year ago

g. Never received

(If your response is e, f, or g): 

THANK YOU. The focus of this survey is on people who used the homemaker service within the 

past year. If it has been more than one year since you received service from a homemaker or 

you only received homemaker service one time, please stop here and go to mailing 

information on page 26. Thank you for your interest in participating.

A2. How long have you been receiving homemaker services?

a. 6 months or less

b. More than 6 months, but less than 1 year

c. At least 1 year, but less than 2 years

d. 2 to 5 years

e. More than 5 years

A3. How often per month does the homemaker help with housework?

______________ Number of times per month

A4. When the homemaker comes, how many hours of help do you receive?

______________ Number of hours of help

A5. Does your homemaker do things the way you want them done?

a. Yes

b. No

A6. Does your homemaker do what you ask them to do?

a. Yes

b. No

A7. How would you rate the quality of your homemaker service?

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

13
A8. Would you recommend the homemaker program to a friend?

a. Yes

b. No

A9. Does the homemaker service help you to continue to live independently? By continue to live 

independently, we mean you are able to stay living where you desire such as in your current 

community and home.

a. Yes

b. No

14
Sections B – H are completed for all five service types.

B. Nutrition 

B1. In the past 12 months, have you tried to get meals, food, or groceries through your Area 

Agency on Aging (AAA)?

a. Yes

b. No (go to B2)

B1a. Were you unable to get food?

a. Yes

b. No (go to B2)

B1b. Were you unable to get meals, food, or groceries from your Area Agency on Aging for any 

of the following reasons?

Please mark all that apply.

a. No response from transportation provider or AAA

b. I was put on a waiting list

c. I was told that I could not have more meals or food

d. I was told there was no more food available

e. I was told there was not enough staff

f. I was unable to pick up the meals or get to the meal pick-up place

B2. Have you recently lost weight without trying? If you are unsure, some things that might 

indicate weight loss are clothes or rings fitting looser, or using a different belt notch.

a. Yes

b. No (go to B3)

B2a. How much weight have you lost?

a. 2-13 lbs

b. 14-23 lbs

c. 24-33 lbs

d. 34 lbs or more

e. Unsure

B3. Have you been eating poorly because of a decreased appetite? For example, eating less 

than 75% of your usual intake. Most often this is due to poor appetite, but there may be other 

reasons sometimes such as chewing or swallowing difficulties.

a. Yes

b. No

B4. Have you recently gained weight without trying?

a. Yes

b. No (go to B5)

c. Unsure (go to B5)

B4a. How much weight have you gained?

_______ Number of pounds

15
Below are several statements that people have made about their food situation. They use the 

terms "we" and "your household". A household includes everyone who lives with you. If you live 

alone, then you are a household of one.

B5. "The food that we bought just didn’t last, and we didn’t have money to get more." Was that 

often, sometimes, or never true for your household in the last 12 months?

a. Often true

b. Sometimes true

c. Never true

B6. "We couldn’t afford to eat balanced meals." Was that often, sometimes, or never true for 

your household in the last 12 months?

a. Often true

b. Sometimes true

c. Never true

B7. In the last 12 months, did you or other adults in your household ever cut the size of your 

meals or skip meals because there wasn’t enough money for food?

a. Yes

b. No (go to B8)

B7a. How often did this happen?

a. Almost every month

b. Some months but not every month

c. Only 1 or 2 months

B8. In the last 12 months, did you ever eat less than you felt you should because there wasn’t 

enough money for food?

a. Yes

b. No

B9. In the last 12 months, were you ever hungry but didn’t eat because there wasn’t enough 

money for food?

a. Yes

b. No

B10 is only asked among Congregate Meals and Home-delivered Meals survey respondents. 

B10. How much do you agree or disagree with this statement...

Since using the meals program through my Area Agency on Aging I have felt more secure about 

having enough food for myself.

1. Strongly Agree

2. Agree

3. Neutral

4. Disagree

5. Strongly Disagree

16
C. Additional Services

C1. These next questions ask about additional help you may have received from your

Area Agency on Aging (AAA). (Please mark all that apply.)

a. In the past year, have you attended a meals program at a senior center or other group 

setting?

b. In the past year, have you received transportation services? (not asked of Transportation 

survey respondents)

c. In the past year, have you received meals or other food from the meals program? (not 

asked of Congregate meals and Home-delivered meals survey respondents)

d. In the past year, have you received Homemaker or Housekeeping services? (These are 

services that may include help with doing light housework, laundry, preparing meals, 

shopping, or delivery of groceries or prescriptions.) (not asked of Homemaker survey 

respondents)

e. In the past year, have you received case management services? (When someone 

receives case management, they have a case manager who may set up in-home 

services, such as homemaker or personal care services for them. The case manager 

may also call to check on how they are doing, or how they like the services.) (not asked 

of Case management survey respondents)

f. In the past year, have you received adult daycare services? (Adult Day Care or adult 

health is when people go to a place to spend the day.)

g. In the past year, have you received personal care services? (Personal care services are 

help with care like dressing or bathing.)

h. In the past year, have you received heavy chore services, such as washing windows, 

yardwork, or shoveling snow? (Chore Services help with heavier housecleaning and 

yard work.)

i. In the past year, have you received legal assistance? (Legal Assistance may help with 

making a will or understanding a bill and other legal matter.)

j. In the past year, have you received information and assistance services? (Information 

and Assistance helps people find out about services that are available to them.)

k. Have you received health screenings such as blood pressure checks from your AAA?

l. Have you received flu shots, pneumonia shots, COVID vaccinations, or other 

immunizations from your AAA?

m. Have you taken exercise or fitness classes or do you use the exercise equipment at a 

senior center or other program for older adults? (Remember, we are asking about 

services received from your AAA).

n. Have you received assistance in administering or monitoring the side effects of medicine 

from your AAA?

o. Have you received help getting benefits like food stamps and other public assistance 

from your AAA?

C2. Did you mark "Yes" to any of the additional services in the table above (items a-n)?

a. Yes

b. No (go to C6)

17
C3. Overall, how would you rate the group of services you receive?

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

C4. Now we would like to ask about how these services help you. Please mark Yes or No for 

each item.

a. As a result of the services you receive are you able to live independently? (By live 

independently, we mean to stay living where you desire such as in your current 

community and home.)

b. As a result of the services you receive do you feel more secure?

c. As a result of the services you receive are you better able to care for yourself?

d. Since you started receiving services, do you have a better idea of how to get any 

additional help that you need?

C5. Thinking about your services in general, do you agree or disagree with this statement?

Please mark if you Agree or Disagree.

a. The people who give these services are generally courteous.

C6. Are you receiving any other types of assistance, such as...? 

Please mark all that apply.

a. Food stamps

b. Energy Assistance

c. Medicaid

d. Housing Assistance

C7. Do your family or friends help arrange for the services you receive?

a. Yes

b. No

D. Falls

The next few questions are about falling down (any fall, slip, or trip in which you lose your 

balance and land on the floor or ground or at a lower level.)

D1. In the last month, have you fallen down?

a. Yes

b. No

D2. In the last month, did you worry about falling down?

a. Yes

b. No (go to E1)

18
D3. In the last month, did this worry ever limit your activities?

a. Yes

b. No

E. Life Changes

E1. We are interested in why you initially sought services from your Area Agency on Aging 

(AAA). What was going on in your life that led you to seek services? 

Please mark all that apply.

a. Illness or medical condition

b. Illness of a person close to you

c. Death of a spouse

d. Problems with mobility

e. Could no longer take care of myself

f. Could no longer take care of my home

g. Want socialization

h. Food and nutrition need

i. Transportation need

j. Accompanied friend/family or referred

k. Financial need

l. Other needs related to aging

F. Social Integration

The next few questions are about your contact with other people.

F1. How often do you feel that you lack companionship?

a. Hardly ever

b. Some of the time

c. Often

F2. How often do you feel left out?

a. Hardly ever

b. Some of the time

c. Often

F3. How often do you feel isolated from others?

a. Hardly ever

b. Some of the time

c. Often

19
G. Physical, Social, and Emotional Well-Being

The next few questions are about your health. Please try to answer as accurately as you can.

G1. In general, how is your health?

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

G2. During the past four weeks, how much of the time have you accomplished less than you 

would like as a result of your physical health?

a. All of the time

b. Most of the time

c. Some of the time

d. A little of the time

e. None of the time

G3. During the past four weeks, how much of the time have you accomplished less than you 

would like as a result of any emotional problems, such as feeling depressed or anxious?

a. All of the time

b. Most of the time

c. Some of the time

d. A little of the time

e. None of the time

G4. During the past four weeks, how much did pain interfere with your normal work, including 

both work outside the home and housework?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

G5. During the past four weeks, how much of the time has your physical health or emotional 

problems interfered with your social activities, like visiting friends, relatives, etc.?

a. All of the time

b. Most of the time

c. Some of the time

d. A little of the time

e. None of the time

G6. Compared with your health one year ago, would you say your health is...

a. Much better

b. A little better

c. About the same

d. A little worse

e. Worse

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G7. Regarding your present social activities, do you feel that you are doing...

a. About enough

b. Too much

c. I would like to be doing more

G8. Have your social opportunities increased since you became involved with your Area Agency 

on Aging (AAA)?

a. Yes

b. No

G9. Now we would like to ask about medical conditions you may have. Has a doctor ever told 

you that you have...?

Please mark all that apply.

a. Arthritis or rheumatism

b. High blood pressure or hypertension

c. A heart attack, coronary heart disease, angina, congestive heart failure, or other heart 

problems

d. High cholesterol

e. Diabetes or high blood sugar

f. Allergies/asthma/emphysema/chronic bronchitis/other breathing or lung problems

g. Cancer or a malignant tumor, excluding minor skin cancer

h. Stroke

i. Anemia (such as iron-deficiency)

j. Osteoporosis

k. Kidney disease

l. Eye or vision conditions such as glaucoma, cataracts, macular degeneration or other 

medical conditions (This does not include needing to wear glasses or contact lenses.)

m. Hearing problems

n. Emotional, nervous or psychiatric problems

o. Memory related disease such as Alzheimer’s or dementia

p. Seizures or epilepsy

q. Parkinson’s disease

r. Persistent pain, aching, stiffness or swelling around a joint (Includes broken bones, 

sprained muscles, bad backs, knees, shoulders, etc.)

s. Multiple Sclerosis

t. A serious problem with urinary incontinence

u. Thyroid disease

v. A digestive or colon-related condition

w. Human immunodeficiency virus (HIV)

x. Something else

G10. Did you mark any of the medical conditions in the table above (items a-x)? 

a. Yes

b. No (go to G14)

G11. During the last 12 months, have you learned how to take care of any or all of your chronic 

illnesses or medical conditions?

a. Yes

b. No

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G12. During the last 12 months, did you talk to a doctor/health professional within your

primary care practice to learn about taking care of any or all of your chronic illnesses

or medical conditions?

a. Yes

b. No

G13. Having one or more illnesses often means doing different tasks and activities to manage 

your conditions. How confident are you that you can do all the things necessary to manage your 

chronic illnesses or medical conditions on a regular basis?

a. Not at all confident

b. A little confident

c. Moderately confident

d. Very confident

G14. Because of a physical, mental or emotional condition lasting 6 months or more, do you 

have any difficulty learning, remembering, or concentrating?

a. Yes

b. No

G15. Do you use a walker, cane, or wheelchair for moving around?

a. Yes

b. No

c. Not applicable – bedridden or bed-bound

G16. About how many different prescription medications do you take every day?

_________

___________ Number of prescription medicines taken per day (if none, enter 0)

G17. In the past 12 months, did you have to stay overnight in a hospital?

a. Yes

b. No

G18. In the past 12 months, did you have to stay overnight in a nursing home or rehabilitation 

center?

a. Yes

b. No

G19. Do you have access to public transportation such as a bus or rail?

a. Yes

b. No

G20a is not asked among Transportation survey respondents because it was asked earlier in 

their survey.

G20a. Is there a car or personal motor vehicle in working condition in your household?

a. Yes

b. No

Now we would like to ask about your oral or dental health, that is, the health of your teeth and 

gums.

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G20b. About how long has it been since you last visited a dentist? Include dental hygienists, 

orthodontists, oral surgeons, and other dental-related specialists. 

a. 6 months or less

b. More than 6 months, but not more than 1 year ago

c. More than 1 year, but not more than 2 years ago

d. More than 2 years, but not more than 3 years ago

e. More than 3 years, but not more than 5 years ago

f. More than 5 years ago

g. Never have been

h. Not applicable – have dentures

G21. During the past 12 months, was there a time when you needed dental care but could not 

get it at that time?

a. Yes

b. No

G22. Overall, how would you rate the health of your teeth and gums?

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

G23. This set of questions is about difficulties with some common activities of everyday life and 

whether you need assistance performing these activities. Please exclude the effects of 

temporary conditions.

Please mark Yes or No for each item.

a. Do you have difficulty when taking a bath or shower?

b. Do you have difficulty when dressing?

c. Do you have difficulty when walking or getting around inside the home?

d. Do you have difficulty eating?

e. Do you have difficulty using the toilet or getting to the toilet?

f. Do you have difficulty getting in or out of bed or a chair?

g. Do you have difficulty keeping track of money or bills?

h. Do you have difficulty preparing meals?

i. Do you have difficulty doing light housework, such as washing dishes or sweeping a 

floor?

j. Do you have difficulty doing heavy housework, such as scrubbing floors or washing 

windows?

k. Do you have difficulty taking the right amount of prescribed medicine at the right time?

l. Do you have difficulty using the phone?

m. Do you have difficulty driving a car or personal motor vehicle?

n. Do you have difficulty using public transportation such as a bus or rail?

o. Do you have difficulty going outside the home, for example to shop or visit a doctor’s 

office?

G24. Did you mark "Yes" to having difficulty with any of the activities above (items a-o)?

a. Yes 

b. No (Go to H1)

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G25. If you marked “Yes” of one or more of the activities in G23, do you need the help of 

another person with any of them?

a. Yes 

b. No (Go to H1)

G26. We would like to know if family or friends provide any help with these activities. If so, who 

helps you the most with these activities? (Mark only one)

a. Husband

b. Wife

c. Partner

d. Son

e. Daughter

f. Daughter-in-law / son-in-law

g. Father / Mother

h. Brother

i. Sister

j. Grandchild

k. Nephew / Niece

l. Other family

m. Neighbor or friend

n. Do not receive help from family or friends

H. Demographics

The purpose of the following questions is to help ACL and its network of AAAs better 

understand the level of satisfaction and needs of all clients based on several types of 

demographic information. The goal is to provide equitable community-based programs and 

support services to all clients. Only ACL’s contracted research team will have access to this 

information. Your responses will be kept confidential and secure. Any reports and studies 

resulting from this survey will summarize information and not identify any individuals. The 

information will not be used for any discriminatory purpose.

H1. What is your age? __________

H2. What is your highest level of education?

a. Less than high school diploma

b. High school diploma or GED

c. Some college, including Associate’s degree (includes business school and vocational or 

technical school)

d. Bachelor’s degree

e. Some post-graduate work or advanced degree

H3. Are you Hispanic or Latino?

a. Yes

b. No

H4. Which one or more of the following best describes your race? Mark all that apply.

a. White

b. Black or African American

c. Asian

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d. American Indian or Alaska Native

e. Native Hawaiian or other Pacific

f. Islander

g. Some other race (specify) _________________

H5. Have you ever served on active duty in the U.S. Armed Forces, military Reserves or 

National Guard? Active duty does not include training for the Reserves or National Guard.

a. Yes

b. No

H6. Is your home located in...

a. The city

b. The suburbs

c. A rural area

d. Don't know

H7. What is your current marital status? 

a. Married

b. Living with a partner

c. Widowed

d. Divorced

e. Separated

f. Never Married

H8. We’d like to ask about the persons who live in your household. Does anyone else live with 

you?

a. Yes

b. No (go to H9)

H8a. If yes...

Please mark Yes or No for each question.

a. Do you live in the home of one of your children?

b. Do one or more of your children live with you?

c. Do you live with other relatives?

d. Do you live with non-relatives?

e. Do you live with your spouse or unmarried partner?

H8b. Including yourself, how many people live in your household?

________ Number of household members

H9. What sex were you assigned at birth, on your original birth certificate?

a. Female

b. Male

c. Prefer not to answer

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H10. What is your current gender? Mark only one.

a. Female

b. Male

c. Transgender

d. Two-Spirit (American Indian or Alaska Native)

e. I use a different term (specify: ____________________) 

f. Prefer not to answer

H11. Which of the following best represents how you think of yourself? Mark only one.

a. Lesbian or gay

b. Straight, that is, not lesbian or gay

c. Bisexual

d. Two-Spirit (American Indian or Alaska Native)

e. I use a different term (specify: ___________________)

f. Prefer not to answer

H12. Thinking about the total combined income from all sources for all persons in your 

household, including income from jobs, Social Security, retirement income, public assistance, 

and all other sources, which category best describes your total household annual income during 

the year 2022?

a. $5,000 or less ($417 or less per month)

b. $5,001 - $10,000 ($418 to $833 per month)

c. $10,001 - $15,000 ($834 to $1,250 per month)

d. $15,001 - $20,000 ($1,251 to $1,666 per month)

e. $20,001 - $25,000 ($1,667 to $2,083 per month)

f. $25,001 - $30,000 ($2,084 to $2,500 per month)

g. $30,001 - $35,000 ($2,501 to $2,917 per month)

h. $35,001 - $40,000 ($2,918 to $3,333 per month)

i. $40,001 - $50,000 ($3,334 to $4,167 per month)

j. Over $50,000 ($4,168 or more per month)

k. Prefer not to answer

H13. Did someone else complete this survey for the person addressed in the letter?

a. Yes

b. No

THANK YOU!

Your answers will help us better evaluate the services funded by the Older Americans Act.

Please return your completed questionnaire in the pre-addressed postage paid envelope to:

Westat

1600 Research Blvd., Room# RCB16

Rockville, MD 20850

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