Connecticut State Plan on Aging Customer Satisfaction Profile Survey 2023

  • Welcome to the State Unit on Aging's Customer Services and Supports Satisfaction Profile Survey, 2023.

    Connecticut Aging and Disability Services - State Unit on Aging

  • This survey aims to gather feedback on your satisfaction with support services received in the past. The State Unit on Aging in the Department of Aging and Disability Services strives to target  underserved older adults to ensure equitable access, promote independence and well-being where they live. Support services offered to our customers include connecting to local services, congregate and home-delivered meals, in-home supports & services,  mental health support,  legal assistance, prevention and health promotion, supporting Caregivers, including grandparents, and transportation.

    All information collected is confidential. Your feedback will help inform planning and policy decisions to advocate for services and supports for older adults and adults with disabilities in Connecticut. need in your community in the coming years, 2024-2027.  

    Your participation in the survey is voluntary. 

    Voluntary Consent: Please note, your voluntary participation in Services and Supports Satisfaction Profile Survey. All information collected is confidential and will be used for analysis and planning for the improvement of access to equitable services and supports to older adults in the State of Connecticut. 

    Your feedback and response in this consumer satisfaction survey is very important.

    Thank you for your participation.

     

  • Thank you for your participation. Please complete all questions and return to the ConnecticutAging and Disability Services State Unit on Aging:

    Email response to:  AgingStatePlan@ct.gov 

  • Section 1: Customer Profile 

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  • 1. What is your relationship to the Customer? (Select one)
  • 2. What County do you live in? (Select one)
  • 4. Marital Status (Select one)
  • 5. Gender (Select one)
  • 6. Sexual Orientation (Select one)
  • 7. Select formal education attained (Select one)
  • 8. Race/Ethnicity (Select one)
  • 9. What is your Employment Status? (Select one)
  • 10. What is your living arrangement? (select one)
  • 11. Estimated Monthly Income: I live alone or with someone other than a spouse and MY income is about: (select one)
  • 12. Estimated Monthly Income: I live with my spouse/partner and OUR monthly income is about: (select one)
  • 13. Primary Language Spoken at Home
  • 14. Type(s) of disability you may have (Select all that apply)

  • SECTION 2: Assessment of Social Service Access

  • 15. Estimated annual out of pocket expense for your healthcare services or support. (Select one)
  • 15. Housing Arrangement (Select one):
  • 16. In the community where you live, do you have access to the following? (Please select all that apply).

  • Section 3: Assessment of Social Isolation 

  • 18. In the past six months, did you experience loneliness or feel isolated? (Select one)
  • 19. Are you able to speak about your feelings of loneliness or social isolation with someone? (Select one)
  • 20. If you experienced loneliness or felt isolated, and are not able to speak about your feelings, are you interested in speaking to someone about your loneliness or social isolation? (Provide contact details at end of survey).

  • Section 4: Assessment of Financial Constraints

  • 21. Have you experience financial hardship in the past 6 months? (Select one)
  • 22. Are you interested in obtaining financial assistance resource and information? (Select one; Please provide your contact details if you would like to receive follow-up support services)

  • Section 5: Assessment of Overall Customer Satisfaction 

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  • Section 6: Assessment of Supports and Services Received.

  • Rows

  • Section 7: Assessment of Need for Additional Services and Supports

  • Rows
  • 26. Do you have access to the following modes of telecommunication? (Select all that apply).
  • 28. Are you a Veteran? (Select one).

  • Contact Details:

    If you indicated, "Yes" to any question and wish to share your contact details, please complete the form below. We will follow-up with you as soon as possible. Thank you.

  • 28. If you indicated you would like to receive further information about assistance or would like to receive additional services and supports not mentioned in this survey, please complete you contact details below.

  • Format: (000) 000-0000.

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    Thank you for your participation into the Connecticut State Plan on Aging Customer Services and Supports Satisfaction Profile Survey.

    Please email us should you have any questions at: agingstateplan@ct.gov 

     

     

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