Q01
Message
All templatesHealthcare & 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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
23 questions · ~10 min
Q02
Multiple Choice
Are you 60 years of age or older?
- Yes
- No
Q03
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
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.
- 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
Opinion Scale
How easy or difficult is it for you to schedule and get to medical appointments?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q06
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
Q07
Ranking
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
Drag to rank
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
Dropdown
What is your age?
- 60–64
- 65–69
- 70–74
- 75–79
- 80–84
- 85+
- Prefer not to say
Q10
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].
Q11
Opinion Scale
How easy or difficult is it for you to live independently in your home today?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q12
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
Q13
Opinion Scale
How easy or difficult is it for you to manage your medications and prescriptions?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q14
Opinion Scale
How affordable are the support services or care you currently receive?
Scale: 1 – 7
Min:Not at all affordableMax:Very affordable
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?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Q18
Opinion Scale
How easy or difficult is it for you to communicate with your healthcare providers (e.g., asking questions, understanding instructions)?
Scale: 1 – 7
Min:Very difficultMax:Very easy
Q19
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)?
Scale: 1 – 7
Min:Not at all comfortableMax:Very comfortable
Q20
Dropdown
Which of the following best describes the area where you live?
- Urban (city center)
- Suburban
- Small town
- Rural
- Prefer not to say
Q21
Multiple Choice
Do you currently live alone?
- Yes
- No
- Prefer not to say
Q22
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
Q23
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
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.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- 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.
What it does well
- 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
Where it falls short
- 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.
What it does well
- 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
Where it falls short
- 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
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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