Dallas Community Health Needs Assessment Survey for Older Adults

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This survey was created by the Senior Vision Coalition to identify the barriers to healthcare, specifically optometry and vision care, older adults face in the Dallas Metroplex. If you need assistance to complete this form or you have any questions, please call (214) 828 -9900 and request to speak with Amanda Tedesco.

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What best describes you? (Check all that apply)

A senior citizen (65 years or older)

A senior citizen (65 years or older) with a disability

A non-senior citizen (younger than 65)

A non-senior citizen (younger than 65) with a disability

A caregiver for a senior citizen

A relative of a senior that needs care

Іншае:

What county do you live in? *

Collin County

Dallas County

Denton County

Ellis County

Johnson County

Kaufman County

Rockwall County

Tarrant County

Іншае:

Please share your ZIP code. *

What is your age group? *

Under 54

55 - 59

60 - 69

70 - 79

80 - 89

90 - 99

100+

What is your gender? *

Male

Female

Non -binary

Prefer to not disclose gender

What is your race or ethnicity? *

Asian

African American or Black

Caucasian or White

Hispanic or Latino

Multiracial or Multiethnic

Native American or Alaska Native

Іншае:

What is the highest level of education you have completed? *

0 -12 years, no diploma

High school diploma/GED

Trade school/Vocational training

Some college, no degree

Associate's degree

Bachelor's degree

Some graduate school

Graduate or professional degree

What is your current employment status? *

Fully retired

Retired but working

Working full-time

Working part-time

Unemployed, looking for work

Unemployed, not looking for work

Homemaker

Disabled

What do you think your household's total income before taxes was for 2021? *

Less than $10,000

$10,000 - $19,999

$20,000 - $29,999

$30,000 - $39,999

$40,000 - $49,999

$50,000 - $59,999

$60,000 - $74,999

$75,000 or more

Don't Know

Which of the following best describes your current relationship status? *

Married

Widowed

Divorced or separated

In a relationship

Single, never married

What type of housing do you currently live in? *

Single family house

An apartment

Retirement facility or Senior Living facility

Nursing home

Homeless

Іншае:

Are you living with family members, non-family members, or alone? *

With family members

With non-family members

With both family and non-family members

Alone

Are you currently a caregiver to someone? *

Yes

Далей

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