SOSMagJulySeptember2020

Type of Assistance Needed NOW How often ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Type of Assistance Needed in the Future How often ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6. Due to the fact that there is no guarantee the person who could help you is free of the Covid-19 virus , please answer the following: Is your need for assistance so serious that you are willing to take the risk of having someone with you in your home, or in a car, to lend you their assistance? ___ I don’t need any type of assistance. ___ Yes, I’m willing to take that risk. ___ No, I’m not willing to take that risk. 7. Do you have any of the following devices (check all that apply): ___ Pad or Android tablet ___ Laptop computer (Windows pc or Mac or I don’t know) ___ Desktop computer (Windows pc or Mac or I don’t know) ( circle one ) ___ Smart phone (Apple iPhone or Android smart phone or I don’t know) ( circle one ) ___ Other smart device (please specify): ____________________________ ___ I do not own any smart devices 8. If you have smart devices, would you like someone to show you how to use it? (check all that apply): ___ Yes, for virtual visits with family and friends ___ Yes, for virtual visits so I can stay home and still have my health care appointments ___ Yes, for virtual visits with a counselor or social worker to help me with my feelings/mental health ___ No, I already know how to use my device for the above needs ___ No, I am not interested in virtual visits Are you feeling any of these emotions from having to stay home or having to stay 6 ft or more away from other people? Check all that apply 9. Angry ___ Depressed ___ Isolated ___ I’m feeling well. It’s not bothering me. ___ Anxious ___ Lonely ___ Afraid ___ Other ___________________________________ 10. Please tell us anything additional regarding what you need now or may need between now and April 2021, in order to maintain your health and your ability to live independently, due to the COVID-19 pandemic. (Use another sheet of paper, if more space is needed.) The survey is anonymous. If you would like Serving Our Seniors to contact you after we read your survey, please provide your phone number and/or e-mail address: _____________________________________ July 2021, in i-Pad or Andr i ta e Type of Assistance Needed NOW How often ____________________________________________________________________________________________ _ _ Type of Assistance Needed in the Future How often ____________________________________________________________________________________________ _ _ _ 6. Due to the fact that there is no guarantee the person who could help you is free of the Covid-19 virus , please answer the following: Is your need for assistance so serious that you are willing to take the risk of having someone with you in your home, or in a car, to lend you their a si tance? ___ I don’t need any type of assistance. _ Yes, I’m willing to ak th t risk. _ No, I’m not w lling to take that risk. 7. Do you have any of the following devices (check all that apply): ___ Pad or Android tabl t _ Laptop computer (Windows pc or Mac or I don’t know) _ Desk ( circle one ) _ Smart phone (Apple iPhone or Android smart phone r I don’t kn w) ( circle one ) _ Other smart device (please specify): ____________________________ _ I do not own any smart devices 8. If you have smart devices, would you like someone to show you how to use it? (check all that apply): ___ Yes, for virtual visits with famil and friends _ Yes, for virtual visits o I can stay home and still have my health care appointments _ Yes, for virtual visits with a counselor or social worker to help me with my feelings/mental health _ No, I already know ho o use my device f r the above needs _ No, I am not interested in virtual visits Are you feeling any of these emotions from having to stay home or having to stay 6 ft or more away from other people? Check ll that apply 9. Angry ___ Depressed ___ Isolated ___ I’m feeling well. It’s not bothering me. ___ Anxious ___ Lonely ___ Afraid ___ Other ___________________________________ 10. Please tell us anything additional regarding what you need now or may need between now and April 2021, in ord r to maintain our he lth a d your ab lity to live indep ndently, due to the COVID-19 pandemic. (Use another sheet of paper, if more space is eeded.) The survey is anonymous. If you would like Serving Our Seniors to contact you after we read your survey, please provide your pho e number and/or e-mail addr ss: _____________________________________ . 14