2020 OHK Annual Assessment Survey

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THANK YOU for completing this assessment, your participation helps OHK secure funding for the Senior Meal Program.

OHK Location You Visit Most Often *

First Name *

Middle Initial

Last Name *

Date of Birth *

YYYY

Primary Phone Number *

Alternate Phone Number

Home Address (House Number, Street Name, Apt Number)

City of Residence *

Zip code of Residence

Program Eligibility *

Marital Status

Household Size

Household Income (your reported income does NOT impact your program participation eligibility) *

Are You Ethnically Hispanic? *

Race (Check all that apply) *

White

Black / African American

Asian

American Indian/Alaska Native

Native Hawaiian/Pacific Islander

Other Multi Racial

Required

Miscellaneous: Check all that apply *

Senior

Disabled

Female Headed Household

Homeless

Required

Employment Status

Gender

Gender at Birth

Sexual Orientation / Identity

Do You Live in a Rural Area?

Nutritional Assessment (check all that apply)

I have a condition that has changed the kind and/or amount of food I eat.

I eat fewer than 2 meals per day.

I eat few fruits or vegetables or milk products.

I have 3 or more alcoholic beverages almost every day.

I have tooth or mouth problems that make eating difficult.

I don’t always have enough money to buy the food I need.

I eat alone most of the time.

I take 3 or more different prescribed over-the-counter drugs daily.

Without wanting to, I have lost or gained 10 pounds in the last 6 months.

I am not always physically able to grocery shop, cook, and/or feed myself.

DISCLAIMER:

I understand that the information I am providing on this form is for registration purposes. I understand that my survey results will only be shared with the Alameda Area Agency on Aging, which may use the information to help identify other services for which I may benefit.

Type your full name on the line below to acknowledge the disclaimer. *

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