ADRC Survey

Organization providing survey support (if applicable) *

N/A - I am filling out for myself

Communities Actively Living Independent and Free (CALIF)

Disability Community Resource Center (DCRC)

Disabled Resources Center, Inc. (DRC)

Independent Living Center of Southern California (ILCSC)

Partners in Care Foundation

Service Center for Independent Life (SCIL)

Southern California Rehabilitation Services for Independent Living (SCRS)

St. Barnabas Senior Services

Wise & Healthy Aging Headquarters

211

Other - please explain in next question

If you answered "other" in previous question, please explain.

I am filling out this survey at a community organization office. *

Yes

No

What is your home zip code? * *

Age *

Sex *

Male

Female

Non-binary

Prefer not to say

Ethnicity (check all that apply) *

Which health insurance do you have (mark all that apply)? *

Medi-CAL

Medicare

Private health insurance

No insurance

Not sure

Type of disability (if any) *

What do you currently need assistance with? *

Do you need language interpretation? *

Yes

No

Do you need child care? *

Yes

No

Maybe

Do you need grocery delivery services? *

Yes

No

Maybe

Do you need medication delivery services? *

Yes

No

Maybe

Do you need household items delivery services? *

Yes

No

Maybe

Do you attend Senior Service Day classes? *

Yes

No

Maybe

I have received support from the Aging and Disability Resource Center (ADRC) or CALIF. (Check all that apply). *

Referral to another service provider

Direct Services

Assistance/navigation support

Follow up

I have not connected with ADRC/CALIF

I connected with ADRC/CALIF but I did not find them helpful

If you responded that ADRC/CALIF has provided you with referral or navigation, to which organizations did they connect you? Mark only one *

If you answered "other" in previous question, please explain

What is biggest barrier you experience in accessing services or meeting your service goals?

Who is providing support for you now? *

Family

Friends

Professional

No one

Other

If other on previous question

Do you have someone to call in case of emergency? *

Yes

No

Maybe

Do you have a cell phone? *

Yes

No

Maybe

Do you have an email account? *

Yes

No

Maybe

How many times have you called 911 in the last 3 months? *

0 Times

1 Times

2 Times

3 Times

4 or more times

How many weeks or months could you afford to pay your expenses if your income got cut off? *

1 week

2 weeks

3 weeks

1 month

3 months

6 months

More than 6 months

Are you concerned that you might lose your home or apartment? *

Yes

No

Maybe

Are you concerned that you might need to move to a nursing home within the next 6 months? *

Yes

No

Maybe

What is your greatest source of concern at the moment?

What are you doing/did you do during COVID-19 (coronavirus)? (check all that apply) *

How much has COVID-19 (coronavirus) impacted your day-to-day life? *

1 - Not at all

2

3

4

5 - Extremely

Which of the following are you experiencing (or did you experience) during COVID-19 (coronavirus)? (check all that apply) *

If other on previous question

From whom have you received services already to address the above issues?

Phone

Aging & Disability Resource Center (LA) Survey

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