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This questionnaire is designed to assist administrators and
planners create the type of living environment that you prefer.
Please answer the questions honestly, with an "X" in the proper
location. All data are considered strictly confidential and will
be used for analysis purposes only.
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What type of building do you prefer?
_ _ _
One Floor |_| Yes |_| No |_| Don't Know
Two Floors |_| Yes |_| No |_| Don't Know
Multifloor |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
What type of individual living quarters do you prefer?
_ _ _
Bedroom Only |_| Yes |_| No |_| Don't Know
Bedroom/Kitchen |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Is a private bathroom necessary?
_ _ _
|_| Yes |_| No |_| Don't Know
__________________________________________________________________
How many people would you be willing to share your room with?
_ _ _
None |_| Yes |_| No |_| Don't Know
One |_| Yes |_| No |_| Don't Know
Two |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Which of these services do you prefer to have within three
blocks ?
_ _ _
Medical Care |_| Yes |_| No |_| Don't Know
McDonald's |_| Yes |_| No |_| Don't Know
Wendy's |_| Yes |_| No |_| Don't Know
Food Store |_| Yes |_| No |_| Don't Know
Drug Store |_| Yes |_| No |_| Don't Know
Church |_| Yes |_| No |_| Don't Know
Library |_| Yes |_| No |_| Don't Know
Bank |_| Yes |_| No |_| Don't Know
Public Park |_| Yes |_| No |_| Don't Know
Bus Stop |_| Yes |_| No |_| Don't Know
Laundromat |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
How many meals should be served daily?
_ _ _
One |_| Yes |_| No |_| Don't Know
Two |_| Yes |_| No |_| Don't Know
Three |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
How should they be presented?
_ _ _
Family Style |_| Yes |_| No |_| Don't Know
Cafeteria Style |_| Yes |_| No |_| Don't Know
Restaurant Style|_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Should these beverages be available?
_ _ _
Milk |_| Yes |_| No |_| Don't Know
Coffee |_| Yes |_| No |_| Don't Know
Beer |_| Yes |_| No |_| Don't Know
Wine |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Should special diets be made available?
_ _ _
Weight Watcher |_| Yes |_| No |_| Don't Know
Low Sodium |_| Yes |_| No |_| Don't Know
Low Fat |_| Yes |_| No |_| Don't Know
Low Cholesterol |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Should these ethnic meals be made available?
_ _ _
Arabic |_| Yes |_| No |_| Don't Know
German |_| Yes |_| No |_| Don't Know
Hungarian |_| Yes |_| No |_| Don't Know
Irish |_| Yes |_| No |_| Don't Know
Kosher |_| Yes |_| No |_| Don't Know
Oriental |_| Yes |_| No |_| Don't Know
Polish |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
How should meals be paid for?
_ _ _
Cash |_| Yes |_| No |_| Don't Know
Credit Card |_| Yes |_| No |_| Don't Know
Food Coupon |_| Yes |_| No |_| Don't Know
Included in rent|_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Which of the following security measures should be available?
_ _ _
Name Tags |_| Yes |_| No |_| Don't Know
ID Badges |_| Yes |_| No |_| Don't Know
Strict Curfew |_| Yes |_| No |_| Don't Know
Security Guard |_| Yes |_| No |_| Don't Know
Lockers |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
What type of visitation privileges should be available?
_ _ _
Family |_| Yes |_| No |_| Don't Know
Friends |_| Yes |_| No |_| Don't Know
Clergy |_| Yes |_| No |_| Don't Know
Unlimited |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Should married couples be allowed to share the same room?
_ _ _
|_| Yes |_| No |_| Don't Know
__________________________________________________________________
Should unmarried couples be allowed to share the same room?
_ _ _
|_| Yes |_| No |_| Don't Know
__________________________________________________________________
Should overnight visiting by family members be allowed?
_ _ _
|_| Yes |_| No |_| Don't Know
__________________________________________________________________
Which of the following types of pets should be allowed?
_ _ _
Bird |_| Yes |_| No |_| Don't Know
Cat |_| Yes |_| No |_| Don't Know
Dog |_| Yes |_| No |_| Don't Know
Fish |_| Yes |_| No |_| Don't Know
Turtle |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Would you consider part time employment in the facility in any
of the following capacities?
_ _ _
Kitchen Work |_| Yes |_| No |_| Don't Know
Laundry Work |_| Yes |_| No |_| Don't Know
Office Work |_| Yes |_| No |_| Don't Know
Telephone Work |_| Yes |_| No |_| Don't Know
Kitchen Mgmt. |_| Yes |_| No |_| Don't Know
Laundry Mgmt. |_| Yes |_| No |_| Don't Know
Office Mgmt. |_| Yes |_| No |_| Don't Know
General Maint. |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Would you consider volunteer work in the facility in any
of the following capacities?
_ _ _
Kitchen Work |_| Yes |_| No |_| Don't Know
Laundry Work |_| Yes |_| No |_| Don't Know
Office Work |_| Yes |_| No |_| Don't Know
Telephone Work |_| Yes |_| No |_| Don't Know
Kitchen Mgmt. |_| Yes |_| No |_| Don't Know
Laundry Mgmt. |_| Yes |_| No |_| Don't Know
Office Mgmt. |_| Yes |_| No |_| Don't Know
General Maint. |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
Would you be interested in any of the following activities?
_ _ _
Bingo |_| Yes |_| No |_| Don't Know
Boating |_| Yes |_| No |_| Don't Know
Book Clubs |_| Yes |_| No |_| Don't Know
Bowling |_| Yes |_| No |_| Don't Know
Bus Tours |_| Yes |_| No |_| Don't Know
Cards |_| Yes |_| No |_| Don't Know
Crafts |_| Yes |_| No |_| Don't Know
Estate Planning |_| Yes |_| No |_| Don't Know
Fishing |_| Yes |_| No |_| Don't Know
Gardening |_| Yes |_| No |_| Don't Know
Golf |_| Yes |_| No |_| Don't Know
Live Performers |_| Yes |_| No |_| Don't Know
Live Theater |_| Yes |_| No |_| Don't Know
Quilting Bee |_| Yes |_| No |_| Don't Know
Sewing Bee |_| Yes |_| No |_| Don't Know
Other _________ |_| Yes |_| No |_| Don't Know
__________________________________________________________________
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Background Information
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Name ......................................................
Address ......................................................
City ......................................................
State ......................................................
Zip Code ......................................................
Telephone ......................................................
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Age ......................................................
Sex ......................................................
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Do you own a car?
_ _ _
|_| Yes |_| No |_| Don't Know
Do you own your home?
_ _ _
|_| Yes |_| No |_| Don't Know
Do you rent your home?
_ _ _
|_| Yes |_| No |_| Don't Know
Do you enjoy the changing seasons? ( Winter, Summer, Fall, etc.)
_ _ _
|_| Yes |_| No |_| Don't Know
Are you employed?
_ _ _
|_| Yes |_| No |_| Don't Know
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The attached questionnaire is a part of a graduate research project
to determine the needs of people living in a retirement or custodial
setting. Please answer these questions truthfully.
All of the information that is collected will be held in strictest
confidence and be used for analysis purposes only.
Please fill in the name and address information where the blanks
indicate. Mark your correct response to the remaining questions
by an " X " or a checkmark.
For Example:
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Age ......................................................
Sex ......................................................
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Do you own a car?
_ _ _
|X| Yes |_| No |_| Don't Know
Do you own your home?
_ _ _
|_| Yes |X| No |_| Don't Know
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