*1.What is your age?(Required.)

35 or younger

36-45

46-55

56-65

65 or older

*2.In what county do you reside?(Required.)

BarbourBerkeleyBooneBraxtonBrookeCabellCalhounClayDoddridgeFayetteGilmerGrantGreenbrierHampshireHancockHardyHarrisonJacksonJeffersonKanawhaLewisLincolnLoganMarionMarshallMasonMcDowellMercerMineralMingoMonongaliaMonroeMorganNicholasOhioPendletonPleasantsPocahontasPrestonPutnamRaleighRandolphRitchieRoaneSummersTaylorTuckerTylerUpshurWayneWebsterWetzelWirtWoodWyoming

*3.What is your sex?(Required.)

Male

Female

Prefer not to answer

*4.What is your ethnicity?(Required.)

White/Caucasian

Black/
African American

Hispanic/Latino

Native American/American Indian

Asian/Pacific Islander

Other

5.What is your yearly household income?

$15,000 or less

$15,001 - $25,000

$25,001-$50,000

$50,001-$75,000

$75,001-$100,000

$100,001 +

*6.How many people reside in your household?(Required.)

1

2

3

4

5 or more

*7.Please indicate your employment status.(Required.)

Part-time employment

Full-time employment

Retired

Unemployed

*8.Which of the following is your PRIMARY connection to Alzheimer's/dementia? (Select one)(Required.)

Person diagnosed with Alzheimer’s/dementia

Spouse or partner of person with Alzheimer’s/dementia

Son, daughter, or other family member of a person with Alzheimer’s/dementia

Friend or acquaintance of a person with Alzheimer’s/dementia

Non-family caregiver of a person with Alzheimer’s/dementia

I work or have worked with people that have Alzheimer’s/dementia

I do not have a primary connection to Alzheimer’s/dementia

*9.Do you provide care for someone with Alzheimer's/ dementia?(Required.)

Yes

No

*10.If you answered "yes" to Question 9, how many hours per week do you provide care to someone with Alzheimer's/dementia?(Required.)

less than 5 hours per week

6-10 hours per week

11-20 hours per week

Over 20 hours per week

Not applicable

11.If you answered YES to Question 9, what type of insurance does the person you care for have?

Medicaid

Medicare

Veterans Benefits

Private Insurance

Uninsured

12.If you answered YES to being a caregiver, how long have you been providing care to an individual with Alzheimer's/dementia?

Less than 1 year

1-2 years

3-5 years

More than 5 years

13.What is the most pressing needs for persons in West Virginia impacted by Alzheimer’s/dementia?

Getting a timely diagnosis

Information about and guidance in finding services and resources upon and beyond diagnosis

Access to services

Affordability of services

Quality of services and resources

Public awareness of the disease

Education and training of health care professionals and caregivers

Community support for family and non-family caregivers of persons with Alzheimer’s/dementia

Other

*14.On a scale of 1-5, with 5 being very satisfied, how satisfied have you been with the following aspects of Alzheimer’s/dementia in West Virginia?(Required.)

1

2

3

4

5

Information about/guidance in finding services and resources beyond diagnosis

1

2

3

4

5

Services and resources available in my area

1

2

3

4

5

Coverage of costs for services and resources

1

2

3

4

5

Quality of services and resources in my area

1

2

3

4

5

Public Awareness of Alzheimer's/dementia

1

2

3

4

5

Education and training of health care professionals and caregivers

1

2

3

4

5

Community support for family and non-family caregivers of persons with Alzheimer’s/dementia

1

2

3

4

5