ACS Survivor Outreach Services Suvivor Assessment Survey
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1. Default Section
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1
. Please provide the following information.
Please provide the following information.
Name:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Email Address:
Phone Number:
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2
. Please provide the name (beginning with the oldest member)of each Surviving Family member in your household.
Please provide the name (beginning with the oldest member)of each Surviving Family member in your household.
1
2
3
4
5
6
7
8
9
10
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3
. Please provide the age, gender, and relationship to the Soldier of each Surviving Family member in your household (same order entered in question #2).
Age
Gender
Relationship to Soldier
1
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
Please provide the age, gender, and relationship to the Soldier of each Surviving Family member in your household (same order entered in question #2). 1 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
2
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
2 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
3
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
3 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
4
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
4 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
5
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
5 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
6
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
6 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
7
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
7 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
8
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
8 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
9
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
9 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
10
0-6 Months
7-11 Months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
10 Age
Male
Female
Gender
Spouse
Parent
Child
Other Relative
Relationship to Soldier
*
4
. Are you aware of the services provided by Survivor Outreach Services (SOS)?
Are you aware of the services provided by Survivor Outreach Services (SOS)?
Yes
No
*
5
. If so, how did you learn about Survivor Outreach Services? (Please check all that apply)
If so, how did you learn about Survivor Outreach Services? (Please check all that apply)
Army One Source
Print Media/Publicity
Command
Family Readiness Support Assistant (FRSA)
Family Readiness Group (FRG)
Friend/Family Member
Other (please specify)
*
6
. Have you utilized any services provided by Survivor Outreach Services?
Have you utilized any services provided by Survivor Outreach Services?
Yes
No
Not Aware of Services
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7
. How far would you be willing to travel for a Survivor Outreach Services (SOS) event?
How far would you be willing to travel for a Survivor Outreach Services (SOS) event?
0-30 Miles
31-60 Miles
61-90 Miles
Over 91 Miles
Do not plan on attending any SOS events
*
8
. Are you or a member of your Family be interested in any of the following (please check all that apply):
Are you or a member of your Family be interested in any of the following (please check all that apply):
Benefit information
Support groups
Children's events
Employment information
Home/Car repair instruction
Focus groups
Self defense class
Social gatherings
Other (please specify)
*
9
. What financial topics interest you?(please check all that apply)
What financial topics interest you?(please check all that apply)
Debt management/Credit repair
Investments
Home buying
College education
Large purchases
Budgeting
Other (please specify)
*
10
. How would you prefer to be contacted?
How would you prefer to be contacted?
Postal mail
Email
Telephone
In person
Do not contact
11
. Additional comments or suggestions?
Additional comments or suggestions?
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