1. Assessed community needs (senior survey and/or needs assessment): (This is the second step in the process after adopting a proclamation or resolution. It is critical that an assessment of the community is completed and that the assessment is a cross section of the community.)

* How was your community assessment or survey disseminated? Please check all that apply.

* How did you ensure that a cross-section of your community participated in the survey or assessment? How many responded? (250 words or fewer)

2. * Advisory Council/Committee: (This group represents a cross section of the community, which may include multi-membership as described in the Blue Print -page 5.)

Please list the areas (e.g., - senior volunteer, academia, business, non-profit, etc.) that your advisory council or committee represents.

3. * Established Partnerships: (It is critical that beyond the advisory group, partnerships are established to include non-traditional aging partners, such as youth and intergenerationa agencies, businesses, employers, faith-based organizations, etc.  This often occurs in the effort to complete specific initiatives within a community.) (500 words or fewer)

Describe two events, programs or services that involved community partnerships. Please list the partners and their contribution to the success of the events, programs or services. 

How did these support your community’s initiative?

4. * Department of Elder Affairs/Area Agency on Aging Partnerships: (Communities that plan and hold events that draw awareness and education to their initiative have a better chance at sustaining their initiative and including or enhancing community support.  Examples include kick-offs,  luncheons, health fairs, media awareness opportunities, etc.) (200 words or fewer)

Describe a program, service or event that included a partnership with the Department of Elder Affairs or your local Area Agency on Aging.

5. * Action Plan: (Indicates that the community strategically planned, identified priorities, set timelines, located additional resources and identified partnerships either on the local, state or federal level.) (350 words or fewer)

Identify three priorities from your action plan, including resources, partnerships and funding sources. How did you incorporate your priorities in support of the initiative?

6. * Policy Change: (The initiative assists local elected officials, community leaders and residents in working together to achieve the goals and benefits of Communities for a Lifetime.)  (250 words or fewer)

Describe a change in your local government policy as a result of your community’s involvement in the initiative (e.g.,  –  zoning, homestead exemption, developing green space, transportation initiatives, building a senior or community center).

7. * Innovative Initiatives: (Communities that are able to bring together new collaborative initiatives often are able to think outside the box and rejuvenate unused or under-used resources.)    (200 words or fewer)

Please list any innovative programs or services that were initiated in your community as a result of Communities for a Lifetime.

8. * Maintenance Plan: (Preparing for an aging process is a continual process.  Reassessment may need to occur when there are leadership changes, population shifts and funding changes.)   (200 words or fewer)

Describe how you will continue to address the needs of residents in your community considering changes that impact leadership, funding, demographics, etc.

9. * Civic Engagement: (Residents want the opportunity to initiate change in their community.)    (200 words or fewer)

How has your initiative engaged individuals in your community in the process?