Q01
メッセージ
すべてのテンプレートHealthcare & Clinical
Aging in Place: Community Needs Assessment for Adults 60+
Assesses daily living challenges, home safety, care coordination, and support priorities among community-dwelling older adults to inform program planning and resource allocation.
設問の例
テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。
全23問・約10分
Q02
選択式
Are you 60 years of age or older?
- Yes
- No
Q03
プルダウン
Which of the following best describes where you live now?
- Single-family home
- Apartment or condo
- Mobile or manufactured home
- Independent senior living community
- Assisted living or similar
- Other
- Prefer not to say
Q04
選択式
In the past 30 days, which of the following tasks have been difficult for you to do at home? Please select all that apply.
- Climbing stairs
- Bathing or showering
- Cooking or meal preparation
- House cleaning or laundry
- Managing medications
- Grocery shopping
- Transportation to appointments
- Using technology or the internet
- None of these
Q05
オピニオンスケール
How easy or difficult is it for you to schedule and get to medical appointments?
スケール: 1 – 7
最小:Very difficult最大:Very easy
Q06
選択式
Who helps you at least once a month? Please select all that apply.
- Spouse or partner
- Adult child
- Other family member
- Neighbor or friend
- Paid home care aide
- Community volunteer
- No one
Q07
ランク付け
Please rank the following improvements from most helpful to least helpful for staying in your home.
- Help with housekeeping
- Transportation services
- Meal delivery
- Medication management tools
- Home safety upgrades
- Social activities or companionship
- Telehealth or virtual visits
ドラッグして順位を付ける
Q08
自由回答（長文）
Based on your responses in this survey, is there anything else you would like to share about your situation or needs for aging in place?
Q09
プルダウン
What is your age?
- 60–64
- 65–69
- 70–74
- 75–79
- 80–84
- 85+
- Prefer not to say
Q10
メッセージ
Thank you for your time and insights. Your responses will be used to help improve programs and supports for aging in place in your community. If you have questions about this survey, please contact [organization name/email].
Q11
オピニオンスケール
How easy or difficult is it for you to live independently in your home today?
スケール: 1 – 7
最小:Very difficult最大:Very easy
Q12
選択式
Which home modifications or assistive devices do you currently use? Please select all that apply.
- Grab bars or handrails
- Shower chair or bench
- Ramps or no-step entry
- Stair lift
- Medical alert button or wearable
- Smart doorbell or camera
- Other (please specify)
- None of these
Q13
オピニオンスケール
How easy or difficult is it for you to manage your medications and prescriptions?
スケール: 1 – 7
最小:Very difficult最大:Very easy
Q14
オピニオンスケール
How affordable are the support services or care you currently receive?
スケール: 1 – 7
最小:Not at all affordable最大:Very affordable
Q15
自由回答（長文）
In your own words, what kind of support would help you most to continue living in your home?
Q16
AIインタビュー
Thank you for sharing your experiences. I'd like to ask a couple of follow-up questions to better understand your needs for aging in place. What is the biggest challenge you face in your daily life at home?
Q17
選択式
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q18
オピニオンスケール
How easy or difficult is it for you to communicate with your healthcare providers (e.g., asking questions, understanding instructions)?
スケール: 1 – 7
最小:Very difficult最大:Very easy
Q19
オピニオンスケール
How comfortable are you using a phone, tablet, or computer for health-related tasks (e.g., scheduling appointments, video visits, accessing test results)?
スケール: 1 – 7
最小:Not at all comfortable最大:Very comfortable
Q20
プルダウン
Which of the following best describes the area where you live?
- Urban (city center)
- Suburban
- Small town
- Rural
- Prefer not to say
Q21
選択式
Do you currently live alone?
- Yes
- No
- Prefer not to say
Q22
プルダウン
What is the highest level of education you have completed?
- Less than high school
- High school or equivalent
- Some college or trade school
- Associate degree
- Bachelor's degree
- Graduate or professional degree
- Prefer not to say
Q23
選択式
Which of the following best describes your current employment status?
- Retired
- Working full-time
- Working part-time
- Homemaker or caregiver
- Unable to work or long-term disability
- Unemployed and looking
- Prefer not to say
含まれる機能
AIによる深掘り
自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。
注意確認設問
急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。
AIが作成する設問文
文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。
自動レポート
回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。
他ツールとの比較
ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。
このテンプレートを選ぶ理由
- Purpose-built for adults 60+, opening with an eligibility screener and covering daily living difficulty, home modifications/assistive devices, medication management, and appointment access in one flow
- Includes a ranking question on which improvements would help most and an open-text question capturing in-their-own-words support needs, giving both quantifiable priorities and qualitative context
- Adds an adaptive AI follow-up interview after the core questions to probe deeper into individual circumstances that fixed-choice questions can't capture
- Closes with demographic and living-situation questions (age, gender, living alone, education, employment, area type) to support equity-focused program planning and resource allocation
Jotform
Home Care Support Worker Intake Form TemplateThis is a fielding-ready intake form, but it's built to onboard home care support workers, not to survey older adults about their own daily living challenges or care priorities. It sits in Jotform's home-care template category and uses standard static form fields. Useful for staffing/intake paperwork, but not a substitute for a community needs assessment of the 60+ population.
優れている点
- Ready-to-use, easily customizable form built on Jotform's mature drag-and-drop builder
- Part of a broad home-care template library, suggesting familiarity with the care-services domain
- Likely supports common form add-ons like e-signatures and file uploads for intake documentation
物足りない点
- Designed for worker intake, not for capturing needs/priorities directly from older adults
- Static question set with no adaptive AI follow-up probing into individual circumstances
- No automated per-response quality scoring or auto-generated analytical report
Typeform
Online Community Needs Assessment Survey TemplateA general-purpose community needs assessment template that could be adapted for many populations, but it is not specifically structured around aging-in-place issues like home safety, care coordination, or medication management. It offers Typeform's polished conversational interface but appears to be a one-size-fits-all starting point rather than a domain-specific instrument. Teams would need to substantially rebuild it to match the depth of an aging-focused assessment.
優れている点
- Typeform's signature conversational, one-question-at-a-time interface is easy for respondents to navigate
- Flexible template that can be adapted to many community populations
- Simple to launch quickly with minimal setup
物足りない点
- Generic community template, not tailored to older-adult daily living, home safety, or care coordination topics
- No adaptive AI follow-up questions to probe individual answers
- No built-in automated quality scoring or auto-generated report for program-planning use
よくあるご質問
「Aging in Place: Community Needs Assessment for Adults 60+」テンプレートにはどのような設問が含まれていますか？
すぐに使える設問が23問含まれており、最初の設問は次のとおりです：「Welcome, and thank you for your interest in this survey. This survey asks about your experience living at home and the k…」・「Are you 60 years of age or older?」・「Which of the following best describes where you live now?」。すべての設問は上でプレビューでき、自由に編集できます。
このアンケートの回答にはどのくらい時間がかかりますか？
回答者は通常、23問を約10分で回答し終えます。
テンプレートは編集できますか？
はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。
このテンプレートは無料で使えますか？
はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。
公開の準備はできましたか？
このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。
関連テンプレート
似たテーマのほかの調査もご覧ください。