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2015
July
S
Survey page 1
Survey page 1
Occupational Therapy and Home Modifications: Promoting Information Literacy
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We are conducting a brief survey of persons 65 years of age and older regarding knowledge and access to information about home modifications and Occupational Therapy in the Montgomery area.
Age category:
Under 65
65-69
70-74
75-79
80-84
85+
Gender:
Male
Female
What are your current living arrangements, in terms of your relation to the people you are living with?
Live with spouse only
Live with spouse and children
Live alone
Other
Do you own or rent your home?
Own
Rent
Other
What is your yearly income?
less than 10,000
10,000-29,999
30,000-49,999
50,000-69,999
70,000-89,999
90,000 or more
Marital status:
Married
Divorced
Widowed
Never been married
Length of stay at current residence
More than 30 years
21-30 years
11-20 years
6-10 years
1-5 years
Less than 1 year
Do you know what home modifications are? If so, in your own words, what are they?
Do you know of any agencies in your city that can help with home assessments and modifications?
Yes
No
Other (Please List those you know)
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