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* 1. What is your 5- digit ZIP Code (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 2. Are you male or female?

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* 3. What is your age as of your last birthday?

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* 4. What is your current marital status?

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* 5. Are you of Hispanic, Spanish, Latino origin or descent?

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* 6. What is your race [CHECK ALL THAT APPLY]

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* 7. What was your annual household income before taxes in the most recent tax year?

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* 8. How would you rate your community as a place for people to live as they age? (This would be the geographical location where your home is located. A community can be located within a city or town or county.)
 

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* 9. How important is it for you to remain in your community as you age?

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* 10. Do you own or rent your primary home — or do you have some other type of living arrangement, such as living with a family member or friend?

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* 11. What type of home is your primary home?

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* 12. How important do you think it is to have the following in your community? 

  Not At All Important Not Very important Somewhat Important Very Important Extremely Important
a) Affordable housing options for adults of varying income levels such as older active adult communities, assisted living and communities with shared facilities and outdoor spaces
b) Homes that are equipped with features such as a no-step entry, wider doorways, first floor bedroom and bath, grab bars in bathrooms 
c) Well-maintained and safe low-income housing 

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* 13. Does the community where you live have the following?

  Not Sure No Yes
a) Affordable housing options for adults of varying income levels, such as older active adult communities, assisted living and communities with shared facilities and outdoor spaces 
b) Homes that are equipped with features such as a no-step entry, wider doorways, first floor bedroom and bath, grab bars in bathrooms

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* 14. How important do you think it is to have the following in your community

  Extremely important Very important Somewhat important Not Very important Not at all important
a) Well-maintained and safe parks that are within walking distance of your home 
b) Public parks with enough benches 
c) Sidewalks that are in good condition, free from obstruction and are safe for pedestrian use and accessible for wheelchairs or other assistive mobility devices
d) Well-maintained public buildings and facilities that are accessible to people of different physical abilities
e) Separate pathways for bicyclists and pedestrians 
f) Well-maintained public restrooms that are accessible to people of different physical abilities 
g) Neighborhood watch programs 

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* 15. Does the community where you live have the following?

  Yes No Not Sure
a) Well-maintained and safe parks that are within walking distance of your home
b) Public parks with enough benches 
c) Sidewalks that are in good condition, free from obstruction and are safe for pedestrian use and accessible for wheelchairs or other assistive mobility devices 
d) Well-maintained public buildings and facilities that are accessible to people of different physical abilities
e) Separate pathways for bicyclists and pedestrians 
f) Well-maintained public restrooms that are accessible to people of different physical abilities 
g) Neighborhood watch programs

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* 16. How important do you think it is to have the following in your community?

  Not At All Important Not Very Important Somewhat Important Very Important Extremely Important
a) Accessible and convenient public transportation 
b) Affordable public transportation
c) Well-maintained public transportation vehicles
d) Reliable public transportation
e) Safe public transportation stops or areas
f) Special transportation services for people with disabilities and older adults
g) Well-maintained streets
h) Easy to read traffic signs
i) Enforced speed limits
j) Public parking lots, spaces and areas to park
k) Affordable public parking
l) Well-lit, safe streets and intersections for all users (pedestrians, bicyclists, drivers)
m) Audio/visual pedestrian crossings
n) Driver education/refresher courses

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* 17. Does the community where you live have the following?

  Yes No Not Sure
a) Accessible and convenient public transportation
b) Affordable public transportation
c) Well-maintained public transportation vehicles
d) Reliable public transportation
e) Safe public transportation stops or areas
f) Special transportation services for people with disabilities and older adults.
g) Well-maintained streets
h) Easy to read traffic signs 
i) Enforced speed limits
j) Public parking lots, spaces and areas to park
k) Affordable public parking
l) Well-lit, safe streets and intersections for all users (pedestrians, bicyclists, drivers) 
m) Audio/visual pedestrian crossings
n) Driver education/refresher courses

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* 18. In general, when compared to most people your age, how would you rate your health?

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* 19. Please imagine a ladder with steps numbered from zero at the bottom to ten at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you.

  0 1 2 3 4 5 6 7 8 9 10
a) Indicate where on the ladder you feel you personally stand right now.
b) On which step do you think you will stand about five years from now

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* 20. Now imagine the top of the ladder represents the best possible financial situation for you, and the bottom of the ladder  represents the worst possible financial situation for you.

  0 1 2 3 4 5 6 7 8 9 10
 Please indicate where on the ladder you stand right now.

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* 21. In general, how would you rate your physical health?

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* 22. In general, how would you rate your mental health, including your mood and your ability to think?

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* 23. How often do you get the social and emotional support you need?

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* 24. How strongly do you agree with this statement "I lead a purposeful and meaningful life"

0 of 24 answered
 

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