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.
What's Included
AI-Powered Questions
Intelligent follow-up questions based on responses
Automated Analysis
Real-time sentiment and insight detection
Smart Distribution
Target the right audience automatically
Detailed Reports
Comprehensive insights and recommendations
Template Overview
23
Questions
AI-Powered
Smart Analysis
Ready-to-Use
Launch in Minutes
This professionally designed survey template helps you gather valuable insights with intelligent question flow and automated analysis.
Sample Survey Items
Q1
Chat Message
Welcome, and thank you for your interest in this survey.
This survey asks about your experience living at home and the kinds of support that might be helpful to you. It should take about 7 minutes to complete.
Your participation is completely voluntary and you may stop at any time. There are no right or wrong answers — we are simply interested in your honest opinions. All responses are confidential and will be reported only in aggregate to help improve programs and services.
Please answer based on your current situation.
Q2
Multiple Choice
Are you 60 years of age or older?
Yes
No
Q3
Dropdown
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
Q4
Opinion Scale
How easy or difficult is it for you to live independently in your home today?
Range: 1 – 7
Min: Very difficultMid: NeutralMax: Very easy
Q5
Multiple Choice
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
Q6
Multiple Choice
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
Q7
Opinion Scale
How easy or difficult is it for you to schedule and get to medical appointments?
Range: 1 – 7
Min: Very difficultMid: NeutralMax: Very easy
Q8
Opinion Scale
How easy or difficult is it for you to manage your medications and prescriptions?
Range: 1 – 7
Min: Very difficultMid: NeutralMax: Very easy
Q9
Opinion Scale
How easy or difficult is it for you to communicate with your healthcare providers (e.g., asking questions, understanding instructions)?
Range: 1 – 7
Min: Very difficultMid: NeutralMax: Very easy
Q10
Multiple Choice
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
Q11
Opinion Scale
How affordable are the support services or care you currently receive?
Range: 1 – 7
Min: Not at all affordableMid: NeutralMax: Very affordable
Q12
Opinion Scale
How comfortable are you using a phone, tablet, or computer for health-related tasks (e.g., scheduling appointments, video visits, accessing test results)?
Range: 1 – 7
Min: Not at all comfortableMid: NeutralMax: Very comfortable
Q13
Ranking
Please rank the following improvements from most helpful to least helpful for staying in your home.
Drag to order (top = most important)
Help with housekeeping
Transportation services
Meal delivery
Medication management tools
Home safety upgrades
Social activities or companionship
Telehealth or virtual visits
Q14
Long Text
In your own words, what kind of support would help you most to continue living in your home?
Max chars
Q15
Long Text
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?
Max chars
Q16
AI Interview
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?
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Reference questions: 7
Q17
Dropdown
What is your age?
60–64
65–69
70–74
75–79
80–84
85+
Prefer not to say
Q18
Multiple Choice
How do you describe your gender?
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Q19
Dropdown
Which of the following best describes the area where you live?
Urban (city center)
Suburban
Small town
Rural
Prefer not to say
Q20
Multiple Choice
Do you currently live alone?
Yes
No
Prefer not to say
Q21
Dropdown
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
Q22
Multiple Choice
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
Q23
Chat Message
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].
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