*1.What is your relationship to the community?(Required.)

Community Resident

Local business owner

Community Organization

Governmental Leader (County, City, Judicial)

Religious Organization

Other (please specify)

*2.What Zip code do you live in?(Required.)

45638

45680

45669

45619

45656

45659

45645

45682

45678

45696

45688

45675

3.What is your current housing situation?

Rent

Own

Staying with friends/family

Homeless or in shelter

Other (please specify)

4.What is your household income level?

Under $15,960

Between $15,961 and $21,640

Between $21,641 and $27,320

Between $27,321 and $33,000

Between $33,001 and $38,680

Between $38,681 and $44,360

Over $44,360

5.How many people are in your household?

1 person (yourself)

2 people

3 people

4 people

5 people

6 people

More than 6 people

6.Do you identify with any of the following groups?

Senior (age 60+)

Person with a disability

Single parent

Veteran

Youth (age 16-24)

None of the above

7.Are you currently employed?

Full-time

Part-time

Self-employed

Unemployed and looking for work

Unemployed and not looking

Retired

8.What is the highest level of education you have completed?

Less than High school

High school diploma or GED

Some college

Associate Degree

Bachelor's degree or higher

9.What do you feel are the top 3 needs in your community right now?

Access to healthcare

Affordable housing

Early childhood education

Job opportunities (finding or keeping a job)

Transportation

Mental health services

Childcare

Mental Health or Substance Use Concerns

Support for seniors

Paying Rent/Mortgage

Paying utility bills

Ability to purchase enough food

Other (please specify)

10.Have you accessed any of the following in the past year?

Food pantry

Utility assistance programs (i.e. HEAP, PIPP)

Job search services (OMJ One-Stop Center)

Head Start/child care

Transportation assistance

Weatherization/home repair

Health care (Family Medical Centers or other FQHC facility)

None of the above

11.How easy is it for you and your family to get medical care when needed?

Very easy

Somewhat easy

Difficult

Very difficult

12.What makes it hard to access services or medical care when needed?

Lack of transportation

Cost of medical care

Difficulty in getting an appointment when you need it

Not knowing what services are available

Long wait times

Office hours don't work for me

Language barriers

Childcare issues

Feel uncomfortable asking for help

None of the above

13.Which types of healthcare services are the hardest to access in our community?

Primary care

Dental care

Vision

Mental health

Substance use treatment

Women's health

Specialty Health care

Other (please specify)

14.If you have children under 5, what are your top concerns?

Affordable childcare

Access to preschool/early learning

Developmental or behavioral issues

Nutritious food access

Non/Not applicable

15.What would "success" look like to your family?

16.What is one thing that would improve your life right now?

17.What are the biggest strengths of our community?

18.What are the biggest challenges in our community?

19.Would you like to stay involved in planning or participate in a focus group?

Yes

No

If yes, please provide your contact information - Phone # or email address (optional)