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Senior Adult Survey

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We often hear people saying that their churches are not providing ministries needed by older adult members. The Church of Saint Monica wants to address these needs and interests. We ask your assistance to get a clearer picture of what is taking place in our parish and what we can do to build stronger senior adult ministries.

The following is a brief survey to help our church obtain information about the needs of older members, women and men 55 years of age and older, and to determine areas of strengths and weaknesses as a basis for developing new ministries.

Once the survey is completed, the responses will be tabulated and presented to the St. Monica community. Thank you for your participation.

PLEASE COMPLETE EITHER AN ONLINE OR WRITTEN SURVEY BY TUESDAY, MARCH 31, 2020.
The maximum number of form submissions has been reached. This form is currently not available.
- Year of Birth REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Male Female Please fill out this field.
- Marital Status REQUIRED Single Married Separated Divorced Widowed Please fill out this field.
- Age Range REQUIRED 55-65 66-79 80+ Please fill out this field.
- Do you live alone? REQUIRED Yes No Please fill out this field.
- If NO, with whom do you live? Spouse Spouse and children Other Family Member Other Care Giver Adult Child Other
- If OTHER, please specify Please enter valid data.
- Do you live in your own home? REQUIRED Yes No Please fill out this field.
- If NO, where do you live? Apartment Community Assisted Living Facility Retirement Community Adult Care Facility (Nursing Home) Home of other family member Other
- If OTHER, please specify Please enter valid data.
- What problems, if any, do you experience with the home or community where you live? If none, please answer none. REQUIRED Please fill out this field.
- How do you rate your general health? REQUIRED Excellent Good Fair Poor Please fill out this field.
- During the past two weeks:
  
  How many times did you participate in a group activity? REQUIRED Please fill out this field. Please enter valid data.
  
  How many times did someone come to visit you? REQUIRED Please fill out this field. Please enter valid data.
  
  How many times did you go to visit someone else? REQUIRED Please fill out this field. Please enter valid data.
  
  How many times did you talk to someone on the phone? REQUIRED Please fill out this field. Please enter valid data.
  
  How many times did you communicate by email? REQUIRED Please fill out this field. Please enter valid data.
  
  How many times did you go shopping? REQUIRED Please fill out this field. Please enter valid data.
- Are you able to attend worship services at church? REQUIRED Yes No Please fill out this field.
- If YES, how often do you attend? Weekly Monthly Occasionally Other
- If OTHER, please specify Please enter valid data.
- Has your level of participation in church activities declined? REQUIRED Yes No Please fill out this field.
- If YES, why? Health Lack of accessibility of church Transportation Caregiving Responsibilities Don't feel I'm able to participate any more Don't feel I am needed any more Other
- If OTHER, please specify Please enter valid data.
- Do you do volunteer work at the church? REQUIRED Yes No Please fill out this field.
- If YES, please specify Please enter valid data.
- Do you do volunteer or paid work in the community? REQUIRED Yes No Please fill out this field.
- If YES, please specify number of hours per week. Please enter valid data.
- If you are unable to attend church, do you participate in worship with any church family by TV or radio? REQUIRED Yes No I'm able to attend church Please fill out this field.
- If YES, what program do you listen to or watch? Please enter valid data.
- Do you believe our church is offering adequate opportunities for activities which support your interests and needs as a senior adult? REQUIRED Yes No Please fill out this field.
- Are there any special programs you would like to see our church develop for senior members? REQUIRED Please fill out this field.
- What issues do you feel older adults in our congregation struggle with the most? REQUIRED Please fill out this field.
- Is there a committee with special responsibility for senior adults in our church? REQUIRED Yes No Please fill out this field.
- If YES, what committee/group? Please enter valid data.
- The remaining questions serve a dual purpose. First, as a senior adult, you have the opportunity to identify the needs and services you would like to be addressed.
  Second, you have an opportunity to offer your services, volunteer, to provide aid and services to other senior members of our community.
- Religious Services:
  
  I would like: REQUIRED Pastoral Counseling Services Holy Communion at home Bible Study Devotional Materials Other Can't think of anything right now. Thanks! Please fill out this field.
  
  If OTHER, please specify Please enter valid data.
  
  I could HELP with religious services by: Please enter valid data.
- Healthcare Service:
  
  I need information about: REQUIRED Medical Care Medications Dental Care Nutrition Home Health Care Other I don't need any information. Thank you! Please fill out this field.
  
  If OTHER, please specify Please enter valid data.
  
  I could HELP with healthcare by: Please enter valid data.
- Transportation:
  
  I need transportation to: REQUIRED Church Work Medical Appointments Shopping Other Home Health Care I don't need transportation Please fill out this field.
  
  If OTHER, please specify Please enter valid data.
  
  I could HELP with transportation by: Please enter valid data.
- Home Repair and Maintenance Services:
  
  I need help with: REQUIRED Lawn Care Painting Ceiling Light Bulbs Carpentry Moving Items Plumbing Electrical Accessibillity (ramp, etc.) Other Nothing, I'm good! Please fill out this field.
  
  If OTHER, please specify Please enter valid data.
  
  I could HELP with home repairs and maintenance by: Please enter valid data.
- Household Assistance:
  
  I need help with: REQUIRED Sewing Cooking Cleaning Laundry Shopping Paying Bills Other I'm OK on my own with this stuff. Please fill out this field.
  
  If OTHER, please specify Please enter valid data.
  
  I could HELP with household assistance by: Please enter valid data.
- Personal Contacts:
  
  I would like: REQUIRED Daily telephone calls Weekly telephone calls Friendly visits Cards and notes from church Other No thanks. I'm good. Please fill out this field.
  
  If OTHER, please specify Please enter valid data.
  
  I could HELP with personal contacts by: Please enter valid data.
- Legal & Financial Service:
  
  I need help with: REQUIRED Social Security Will Planning Retirement Planning Budgeting Medicare/Medicaid Other Don't need help with any of these. Please fill out this field.
  
  If OTHER, please specify Please enter valid data.
  
  I could HELP with legal & financial services by: Please enter valid data.
- Educational Services:
  
  I am interested in: REQUIRED Classes/seminars Home Safety Computer/Internet Videos/DVDs Large Print Books Audio Books Other None of this. Please fill out this field.
  
  If OTHER, please specify Please enter valid data.
  
  I could HELP with educational services by: Please enter valid data.
- Other issues and suggestions for senior adult activities or volunteer opportunities.
- That's it. Thank you so much. Please make sure to click on the SUBMIT button right below this message.
Submit

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