Elderberry Institute-Community Profile Worksheet

Volunteer Form

Living at Home/Block Nurse Program Community Profile

Instructions:
Plan to spend about 45 minutes or so filling in the requested information about your community. If you find that there seem to be a sufficient number of seniors (persons aged 65 or older) in your area with a genuine need for the types of services offered by a Living at Home/Block Nurse Program, and you are aware of others like you with an interest in helping elders who will join with you, you may very well be on your way to founding a Program in your community! We also suggest that you use the helpful, free document, Forming A Community-Based Network (pdf), as a "handbook" to facilitate your initial efforts.

If you discover that you're unable to complete the Profile in one sitting, do what you can now, and then click the "Finish Later" button. You'll be asked to create a username and password. When you return to this website to complete your work, click "Retrieve Assessment Form", enter your ID information, and you'll be able to complete your work.

When you finish filling out the Profile, you may also print a copy for yourself. Then, click the "Send" button to send the information to Elderberry Institute. We will contact you shortly to offer additional help with starting a Living at Home/Block Nurse Program in your area.

Personal Information
First Name*
Middle Initial
Last Name*
Birthdate
Gender
Address 1*
Address 2
City*
State*
Zip Code*
Home Phone*
Work Phone
Email Address

Community Demographics

Population
Total population in targeted area
Number of people over age 65	% of population
Number of people over age 75	% of population
Minority Population	% of population

Race
Predominant race
Largest minority

Socio-economic status
Average education level	HS graduate	College graduate

Home ownership
Number of owner-occupied homes
Percent of owner-occupied homes

Employment
No. of employed females	% of population
No. of employed males	% of population

Median income
Family income
Household income

Poverty
Number of poor persons	% of population
Number of poor families	% of population
No. of people approved for public assistance	% of population

Occupation
Predominant Occupations:

Community Leaders (People whose influence in the community is well known)

Community Organizations
Churches:

Service Organizations (check those that apply):
Lions Club Rotary Club Junior League Boy Scouts Red Cross Others (please list)

Other Civic Organizations (Check those that apply and list the relevant organizations):
Senior citizens' advocacy groups
Women's groups
Church organizations

Governmental agencies, elected officials (Check those that apply and list the relevant organizations, individuals)
Social service organizations
Aging/Health Agencies
Legislators
Local City Officials

Other Senior Resources (Check those that apply and list the relevant organizations):
Hospital(s)
Health Maintenance Organization(s)
Nursing Home(s)
Senior Day Care Center(s)
Senior Recreational Center(s)
Nutrition Center(s) for Seniors
Others (please list)

Other Senior Resources (Check those that apply and list the relevant organizations):
Transportation Services
Meal Services
Grocery Delivery
Food Shelves
Homemaking/Chore Services

Key People/Organizations

Now, go back over the previous lists and place a "check" next to the names of those leaders, organizations or groups whose support or involvement is important to ensure the success of a LAH/BNP.
In the space, list the community leaders, organizations or groups from the list above that have not shown interest in a LAH/BNP.
What needs to be done to get their support and involvement?
What agencies provide health and long?term home care (e.g., home health agencies, HMOs) in the wider community?
What informal linkages and networks exist in the community that in some way support the needs of seniors? (For example, is the leisure center for seniors in a specific church? Is the local 4?H leader involved in another community activity? Do the local pastors meet periodically?)

Communication Channels

Communication Channels
What communication systems can be used to promote or communicate information about a LAH/BNP? Check those that apply below.
Newspapers Radio Television Bulletin Boards Newsletters Church Bulletins
Other vehicles within organizations and agencies (please specify).
How do community residents get information about important community issues?
Do residents come to community meetings? Yes No
What civic and social groups might welcome a speaker regarding services for seniors? Who are the contact persons within those organizations?

Cultural Norms

Cultural Norms
Who are the informal leaders?
What is the economic climate like in the community?
How do community leaders and key organizations view seniors and their needs?
What is the political and organizational environment like in the community? Do the organizations that work on behalf of seniors work well together or is there a lot of infighting?
What issues, values and attitudes do community residents hold in common? What issues currently create conflict in the community? What issues bring community residents and groups together?
What are the community's strengths and weaknesses? Is the city or town council effective? What about other community leaders?

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