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Test Survey
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Test Survey
1
How would you describe your current housing situation?
Select one answer
Own home
Rent home
Assisted living facility
Living with family and others
Other (please specify)
2
Below is a list of materials used in the home. Please tell use if you use these materials. (Select one response for each row)
Select one answer in each row
I have this in my home
I have and use this in my home
I do not require this at my home
Grab bars or handrails
Stair lift or home elevator
Mobility aid (ex. cane, walker, wheelchair)
Raised toiler seat or walk-in shower
Emergency call system or medical alert device
Adequate lighting in all areas
Removed tripping hazard
Other
3
Please list how many of your household members fall in each age range listed below.
Complete todos los siguientes campos
Number of Children from 0 to 18 years old
Number of Adults from 19 to 59 years old
Number of Adults from 60 to 69 years old
Number of Adults from 70 years and above
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