Introduction: Thank you for participating. This survey helps us understand community needs and improve services. Your responses are confidential and will only be reported in summary form.
Section 1: Basic Information

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* 1. County

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* 2. Zip Code

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* 3. Age

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* 4. Gender

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* 5. Race (Check all that apply)

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* 6. Household Size

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* 7. Children Under 18

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* 8. Adults over 60

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* 9. What is the highest level of education you've received?

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* 10. Total Household Yearly Income (before taxes)

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* 11. What types of income does your household receive? (Check all that apply)

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* 12. What assistance programs have you participated in? (Check all that apply)

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* 13. Do you identify as (Check all that apply)

Section 2: Housing Stability

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* 14. Current housing situation:

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* 15. Main source of heat

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* 16. In the past 12 months, have you: (check all that apply)

Section 3: Food and Nutrition

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* 17. Do you have access to fresh fruits and vegetables regularly?

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* 18. Do you or someone in your household have special dietary needs? (check all that apply)

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* 19. In the past 12 months, did you experience any of the following? (check all that apply)

Section 4: Financial

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* 20. Check the following that apply to you.

Section 5: Transportation

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* 21. What is your primary transportation?

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* 22. In the past 12 months, have you experienced the following? (check all that apply)

Section 6: Employment

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* 23. Employment Status

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* 24. In the past 12 months, have you experienced any of the following? (check all that apply)

Section 7: Childcare
(answer if applicable)

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* 25. In the past 12 months, have you experienced any of the following? (check all that apply)

Section 8: Physical and Mental Health

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* 26. Do you have health insurance?

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* 27. In the past 12 months, did you delay your medical care due to any of the following? (check all that apply)

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* 28. Have you needed mental health services but were unable to access them?

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* 29. In the past 12 months, have you experienced: (check all that apply)

Section 9: Seniors (65+)
(answer if applicable)

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* 30. Do you feel socially isolated?

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* 31. Do you need assistance with any of the following: (check all that apply)

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* 32. Do you have access to senior programs or social activities?

Section 10: Individuals with Disabilities
(answer if applicable)

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* 33. Do you experience difficulty accessing any of the following? (check all that apply)

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* 34. Do you need any of the following? (check all that apply)

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* 35. Are community services physically accessible?

Section 11: Community Feedback

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* 36. Rank your biggest worries for yourself and the people around you:

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* 37. What services are missing in your community?

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* 38. What would improve your quality of life the most right now?

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* 39. What prevents you from getting the services you need?

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