Needs Assessment Step 1 of 2 50% Name* First Last Date* Date Format: MM slash DD slash YYYY Center*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxContact*TitleEmail* Describe your facility (adult day program, assisted living, etc.):*How many seniors does your center serve?*What are your hours of operation? What one hour time slots do you have available for programming?*Please briefly describe the space you have available in which to conduct workshops. (Carpeted or tile; #tables; participant capacity; sink, etc.):*How is your center primarily funded?*Please attach most recent annual report if applicable.What are your expectations for AFTA programming?* GenderNumber of MalesNumber of FemalesAgeNumber of those up to 65 years of ageNumber of those 65-75 years of ageNumber of those 75-85 years of ageNumber of those 85-95 years of ageNumber of those 95+ years of ageRacial/Ethnic Make-up:Number of Asian AmericansNumber of Black or African AmericansNumber of Hispanic or Latino AmericansNumber of Native AmericansNumber of Native Hawaiian and other Pacific IslandersNumber of White AmericansNumber of two or more racesNumber of some other raceSocio-Economic demographics:Number of private paid patientsNumber of commercially insured patientsNumber of medicare patientsNumber of medicaid patientsPhysical/Cognitive impairments:Number of those with vision impairmentsNumber of those with hearing impairmentNumber of those with history of CVA (stroke)Number of those with dementiaWith those with Dementia, what is the number of those diagnosed with Alzheimer’s diseaseNumber of those with Other (MS/ALS)Physical/Cognitive impairments:Number of those alert and orientedNumber of those mildly forgetful/confusedNumber of those moderate cognitive impairmentNumber of those severe cognitive impairmentPhysical ability:Number of IndependentNumber of those who use can or walkerNumber of wheelchair boundNumber of bed boundGeneral Ability:Number of those who need verbal cuesNumber of those who need hands-on assistanceNumber of independent and participatoryNumber of those who observe only
