Q01
Long Text
All templates
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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
23 questions · ~4 min
Q02
Multiple Choice
Are you 60 years of age or older?
Q03
Long Text
Which of the following best describes where you live now?
Q04
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.
Q05
Long Text
How easy or difficult is it for you to schedule and get to medical appointments?
Q06
Multiple Choice
Who helps you at least once a month? Please select all that apply.
Q07
Long Text
Please rank the following improvements from most helpful to least helpful for staying in your home.
Q08
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?
Q09
Long Text
What is your age?
Q10
Long Text
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
Long Text
How easy or difficult is it for you to live independently in your home today?
Q12
Multiple Choice
Which home modifications or assistive devices do you currently use? Please select all that apply.
Q13
Long Text
How easy or difficult is it for you to manage your medications and prescriptions?
Q14
Long Text
How affordable are the support services or care you currently receive?
Q15
Long Text
In your own words, what kind of support would help you most to continue living in your home?
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?
Q17
Multiple Choice
How do you describe your gender?
Q18
Long Text
How easy or difficult is it for you to communicate with your healthcare providers (e.g., asking questions, understanding instructions)?
Q19
Long Text
How comfortable are you using a phone, tablet, or computer for health-related tasks (e.g., scheduling appointments, video visits, accessing test results)?
Q20
Long Text
Which of the following best describes the area where you live?
Q21
Multiple Choice
Do you currently live alone?
Q22
Long Text
What is the highest level of education you have completed?
Q23
Multiple Choice
Which of the following best describes your current employment status?
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.