Assessment

Are you taking this survey for yourself or are you taking it on behalf of someone else?

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Myself Someone else

Please rate your level of agreement with the following statements:

I feel isolated from others

* Required
None of the Time Some of the Time Often

I lack companionship

* Required
None of the Time Some of the Time Often

I feel no one really knows me well

* Required
None of the Time Some of the Time Often

I can find companionship when I want it

* Required
None of the Time Some of the Time Often

In the past two weeks, I have participated in organizations such as: Social clubs, residents’ groups, or committees

* Required
None of the Time Some of the Time Often

In the past two weeks, I have participated in: Religious groups

* Required
None of the Time Some of the Time Often

I avoid socializing because it is hard to understand conversations, especially when there is background noise

* Required
None of the Time Some of the Time Often

I am satisfied with the relationships I have with my family

* Required
None of the Time Some of the Time Often

I am satisfied with the relationships I have with my friends

* Required
None of the Time Some of the Time Often

I have as much contact as I would like with people I feel close to and who I can trust and confide

* Required
None of the Time Some of the Time Often

There are enough people I feel close to and could call for help

* Required
None of the Time Some of the Time Often

I am content with my friendships and relationships

* Required
None of the Time Some of the Time Often

I miss having people around me

* Required
None of the Time Some of the Time Often

Please tell us a little about you. What is the 5-digit ZIP Code where you live?

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In what year were you born (YYYY)?

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What is your gender?

* Required
Male Female Transgender Prefer to self-describe

Are you of Hispanic, Latino, or Spanish origin or descent?

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Yes No

Which of the following best describes your race?

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American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White or Caucasian Multi-racial Other Race

Do you live alone?

* Required
Yes No

Are you married or do you live with a partner?

Yes No

Have you ever served in the military?

* Required
Yes No

Are you blind or do you have difficulty seeing, even when wearing glasses?

* Required
Yes No

Are you deaf or do you have difficulty hearing?

* Required
Yes No

Do you have difficulty walking or climbing stairs?

* Required
Yes No

Are you worried or stressed about having enough money to meet your basic needs?

* Required
Yes No

Do you have a ride or the transportation you need to get where you want to go?

* Required
Yes No

Do you own a smartphone, computer, laptop, or tablet?

* Required
Yes No

Which of the following best represents how you think of yourself?

* Required
Heterosexual (Straight) Gay Bisexual Something else I prefer not to answer

Assessment

Are you taking this survey for yourself or are you taking it on behalf of someone else?

Please rate your level of agreement with the following statements: I feel isolated from others

I lack companionship

I feel no one really knows me well

I can find companionship when I want it

In the past two weeks, I have participated in organizations such as: Social clubs, residents’ groups, or committees

In the past two weeks, I have participated in: Religious groups

I avoid socializing because it is hard to understand conversations, especially when there is background noise

I am satisfied with the relationships I have with my family

I am satisfied with the relationships I have with my friends

I have as much contact as I would like with people I feel close to and who I can trust and confide

There are enough people I feel close to and could call for help

I am content with my friendships and relationships

I miss having people around me

Please tell us a little about you. What is the 5-digit ZIP Code where you live?

In what year were you born (YYYY)?

What is your gender?

Are you of Hispanic, Latino, or Spanish origin or descent?

Which of the following best describes your race?

Do you live alone?

Are you married or do you live with a partner?

Have you ever served in the military?

Are you blind or do you have difficulty seeing, even when wearing glasses?

Are you deaf or do you have difficulty hearing?

Do you have difficulty walking or climbing stairs?

Are you worried or stressed about having enough money to meet your basic needs?

Do you have a ride or the transportation you need to get where you want to go?

Do you own a smartphone, computer, laptop, or tablet?

Which of the following best represents how you think of yourself?

Please click "Continue" to leave the Commit to Connect website.

Please rate your level of agreement with the following statements:

I feel isolated from others