LGBT Needs Assessment Survey City of Los Angeles Department of Aging 2016-2020 Area Plan 1. Do you identify as LGBT (Lesbian-Gay-Bisexual-Transgender) a. Lesbian b. Gay c. Bisexual d. Transgender e. Other:______________________ f. Heterosexual (End interview. This survey is for members of the LGBT community) 2. What is your age a. Under 50 (This ends our interview. This survey is for the older adult community) b. 50 – 54 c. 55 – 59 d. 60 – 64 e. 65 – 69 f. 70 – 74 g. 75 and over 3. What is your gender? a. Male b. Female c. Transgender 4. What is your racial/ethnic background? a. Alaska Native/Native American b. Asian: Chinese c. Asian: Japanese d. Asian: Korean e. Asian: Vietnamese f. Asian: Other g. Black/African American h. Hispanic/Latino: Mexican/Mexican American i. Hispanic/Latino: Cuban j. Hispanic/Latino: Puerto Rican k. Hispanic/Latino: Central American l. Hispanic/Latino: Other m. Native Hawaiian/Pacific Islander n. White o. Multi-racial p. Other
5. What is your living situation? a. Live alone b. Live with spouse/partner c. Live with son/daughter d. Live with other family/relatives e. Live with non-relatives f. Other 6. Do you usually have enough money to pay for your regular expenses? a. Yes b. No 7. During the past year, have you faced social discrimination due to ageism, homophobia or heterosexism? a. Yes b. No 8. During the past year, have you faced antigay or gender discrimination by social services providers (agencies offering food stamps, meals, in-home support)? a. Yes b. No 9. If yes to question 8, did it impede your access to services? a. Yes b. No 10. Have you faced antigay or gender discrimination related to senior housing? a. Yes b. No 11. Do you feel socially accepted in community or senior centers that are not identified as “Gay Friendly” or “LGBT Friendly” a. Yes b. No 12. Would you feel more comfortable using services if the service provider was identified as “Gay Friendly” or “LGBT Friendly”? a. Yes b. No
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13. Please check all the items that concern you: Concern
a. Planning for my future care needs b. A serious fall c. Loneliness/Depression d. Finding services/benefits to help me e. Having enough food to eat f. Getting medical care that I need g. Understanding my health care options h. Paying for medications i. Paying doctor/hospital bills j. Getting legal help k. Ability to continue driving safely l. Being taken advantage of or abused m. Getting transportation n. Paying energy/utility bill o. Paying for housing/ finding affordable & safe housing p. Dealing with Alzheimer’s or other dementia q. Staying socially active r. Finding a job s. Caring for spouse/partner/adult relative t. Finding a reliable person to do in home care u. Other: v. Other:
Now
In the Next 4 years
Not at all / Does not apply
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14. How would you rate the City of Los Angeles in providing the following to its LGBT residents: Excellent Very Good a. Affordable LGBT affirming elder housing b. Culturally Competent Care c. Community Acceptance d. Social Services e. LBGT Senior Activities f. Health Care g. Personal Safety
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Poor
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15. During the past year, have you received any social services such as Congregate Meals, Home Delivered Meals, Transportation or Case Management from a senior or adult community center in the City of Los Angeles? a. Yes (go to question 16) b. No (This concludes the interview) 16. If yes to question 15, how would you rate the services you received? a. Excellent b. Very Good c. Good d. Fair e. Poor 17. If yes to question 15, were you helped by the services you received? a. Yes (go to question 18) b. No (This concludes the Interview) 18. How were you helped by the services provided? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Conclude Interview
Office Use Only Survey Interviewer Date Location
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