Linn County: Innovations in Nutrition Program 

Awareness Questionnaire 

The purpose of this questionnaire is to assess your awareness of the nutrition programs 

and services offered by the Heritage Area Agency on Aging. 

Thank you for your assistance! 
 

 

Please circle the appropriate number to indicate your level of awareness about the following services BEFORE 

November 2017 and AFTER September 2018. 

Please use the following key for rating: 

1. Very Low (Don’t know anything about this program or service)

2. Low (Know very little about this program or service) 

3. Moderate (Aware of this program or service but there are more things to learn) 

4. High (Have a good knowledge about this program or service but there are things to learn) 

5. Very High (Know almost everything about this program or service) 

How do you rate your 

awareness about: 

BEFORE NOVEMBER 2017 AFTER SEPTEMBER 2018 

Very 

Low 

Low Moderate High Very 

High 

Very 

Low 

Low Moderate High Very 

High 

Adult day care/day 

health 

1 2 3 4 5 1 2 3 4 5 

Assisted transportation 1 2 3 4 5 1 2 3 4 5 

Chore (help in the 

home) 

1 2 3 4 5 1 2 3 4 5 

Congregate Meal 

Program 

1 2 3 4 5 1 2 3 4 5 

Elder Abuse 

Prevention Awareness 

(EAPA) assessment 

and intervention 

1 2 3 4 5 1 2 3 4 5 

EAPA counseling 1 2 3 4 5 1 2 3 4 5 

Evidence-based health 

programs, i.e. fall 

prevention, Chronic 

Disease SelfManagement 

1 2 3 4 5 1 2 3 4 5 

Health promotion, 

disease prevention 

1 2 3 4 5 1 2 3 4 5 

Homemaker 1 2 3 4 5 1 2 3 4 5 
 

 

 

Please use the following key for rating: 

1. Very Low (Don’t know anything about this program or service)

2. Low (Know very little about this program or service) 

3. Moderate (Aware of this program or service but there are more things to learn) 

4. High (Have a good knowledge about this program or service but there are things to learn) 

5. Very High (Know almost everything about this program or service) 

How do you rate your 

awareness about: 

BEFORE NOVEMBER 2017 AFTER SEPTEMBER 2018 

Very 

Low 

Low Moderate High Very 

High 

Very 

Low 

Low Moderate High Very 

High 

Material aid 1 2 3 4 5 1 2 3 4 5 

Nutrition Education 1 2 3 4 5 1 2 3 4 5 

Options counseling 1 2 3 4 5 1 2 3 4 5 

Personal care 1 2 3 4 5 1 2 3 4 5 

Transportation 1 2 3 4 5 1 2 3 4 5 

The following questions provide us with information about those who are completing the questionnaire. 

1. Select the type of agency/organizations for whom you work. (Mark all that apply) 

 Area Agency on Aging 

Church 

Department of Human Services 

Extension and Outreach 

Home health 

Hospital 

Library 













 Nursing home 

Private health care practice 

Public health department 

Retirement community/Senior housing 

Volunteer agency 

Other (please specify)











2. How long have you worked for your current agency/organization? 

Months Year(s) 
3. Before November 2017, how likely were you to refer adults age 60 years and older to the congregate meal program 

and services? 

Very Unlikely Somewhat Unlikely Neutral Somewhat Likely Very Likely 

    

4. After September 2018, how likely are you to refer adults age 60 years and older to the congregate meal program and 

services? 

Very Unlikely Somewhat Unlikely Neutral Somewhat Likely Very Likely 

    

5. Between November 2017 and September 2018, how many adults age 60 years and older have you referred to the 

congregate meal program and services? 

 None 

1 to 4 

5 to 9 

10 to 14 

15+ 









END OF QUESTIONNAIRE. THANK YOU.