2016 Shepherd's Center Survey
Shepherd Center’s Community Survey 2016
A project of Shepherd’s Center of the Cannon Valley
Shepherd’s Center is currently exploring ways to expand services that would assist seniors to remain independent in their own homes as they grow older. We are conducting a community survey to determine how to better serve our residents. To ensure that services will meet actual needs, Shepherd’s Center would appreciate your feedback. Our intent is not to duplicate programs already provided by others, but to determine if we might be able to offer more.
Your feedback is critical. Without it we cannot develop a service that will meet current of future needs.
Please complete the survey and mail it OR you may drop it off at the Shepherd’s Center at 120 West State Street in Cannon Falls. Results will be published when complete. Please return your input by September 1, 2016.
Please answer the following questions:
1. Where do you currently live?
____Cannon Falls ____Rural Cannon Falls ___Other, please list___________________________
2. What is your age?
_____55-59 _____60-64 _____65-69 _____70-74 _____75-79 _____80-84 _____85+
3. Who do you currently live with? ____Alone _____Other (spouse, family, friend)
4. Have you fallen in the last year? _____ Yes _____No
5. Would you like to be able to get out of your house more often? _____Yes _____No
6. Do you have family or friends with whom you visit or talk on the phone with on a frequent basis?
7. Would you appreciate regular phone calls to check on how you are doing or if you need something?
8. Which of the following services would have been beneficial to you during the past year? (Check all that apply)
_____Social activities _____Preparing meals _____Chores
_____Transportation _____Home maintenance _____Cleaning
_____Laundry _____Housekeeping _____Shopping
_____Caregiver respite _____Getting my prescriptions _____Errands
_____Lawn care _____Snow shoveling _____House repairs
_____Personal visits _____Grocery Delivery _____ Other. Please list
9. What would you identify as the top 2 services that would assist you/loved ones to remain in their home? 1) ______________________________________________________________
10. Is transportation available when you need it? _____Yes _____No
11. How much does your health limit activities such as moving a table, vacuuming, lawn mowing or snow shoveling. _____Limits a lot _____Limits a little _____No limit at all
12. If you needed help to remain at home, how would you prioritize the following service possibilities? (Please number each item from 1 to 10, with 1 being the first item you would purchase and 10 being the last.)
_____Respite (Someone to come to my house to stay with spouse/parent to give you relief)
_____Someone to come to my home to help with housekeeping, laundry or meal preparation
_____Someone to come to my home to help me with personal care
_____Repairs or maintenance to my home
_____Someone to help arrange services for me
_____Transportation for out-of-town medical appointments
_____Transportation for groceries, prescriptions, etc.
_____Transportation to social events or church services
_____Someone to mow my lawn or shovel my snow
_____Other, please list
13. Do you frequently provide care for someone who is unable to do things for them self, due to illness, injury or disability?
14. How effective is Cannon Falls in offering services to help senior residents remain in their homes for as long as possible?
_____Excellent _____Good _____Fair _____Poor
If you would like to be informed of developments, please give us your contact information (optional).
PHONE _________________ EMAIL ______________________
Shepherd’s Center of the Cannon Valley
For completing this survey!
Shepherd’s Center120 W. State St
Cannon Falls, MN 55009
Contact us at: (507) 263-2136
Email to: firstname.lastname@example.org