Senior Accessibility Needs Assessment Survey Form
Please share the accessibility needs, preferences, and support requirements that would make services easier and more comfortable for you.
Respondent Profile
Full Name
*
First Name
Last Name
Preferred Contact Method
*
Phone
Email
Text Message
Caregiver Contact
Age Range
*
Please Select
60–64
65–69
70–74
75–79
80–84
85+
Environment and Service Accessibility
Accessibility accommodations needed in service settings
*
Wheelchair-accessible entrances
Accessible seating availability
Quiet waiting area
Accessible restrooms
Handrails
Elevator access
Assistance with forms or check-in
Other
Key limitations or areas where support is most needed
Technology and Digital Access
Primary device or access method
*
Phone
Tablet
Computer
In-person only
Digital accessibility support needs
Larger text
Simplified navigation
Voice assistance
Help completing online forms or portals
Screen reader support
Magnification
Other
Submit
Should be Empty: