Eligible Family Survey

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1. Which county do you live in?

Which county do you live in?   Crawford Sebastian

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2. What is your zip code?

What is your zip code?

3. How long have you lived in this county?

How long have you lived in this county?   0-5 years 5-10 years 10-15 years 15-20 years 20 years

4. Of this list, which 8 issues concern you the most in your neighborhood or community?

Of this list, which 8 issues concern you the most in your neighborhood or community?   Need more job training Not enough jobs Adult Education Schools and education for children Safety in schools Condition of school buildings and facilities Illiteracy Language barriers Money management Need affordable housing Lack of shelter for homeless families Food for low income people Food for the elderly Available health care Emergency services Available mental health care Services for disabled children and families Lack of transportation Roads and street repair Cost of utilities Lack of quality child care Acces to Library or Bookmobile Teen pregnancy Teenage deliquency Crime, violence, and drug abuse Child abuse and neglect Vacant buildings and run down houses

5. Of this list, which 6 are the most pressing issues for your family?

Of this list, which 6 are the most pressing issues for your family?   Job training Employment Educational services for children Education for adults Lack of books or reading materials in the home Paying necessary bills Managing finances Tax return preparation and filing Affordable housing Housing maintenance and repair Food Transportation and fuel costs Available telephone or cell phone Getting help for personal needs (baths, etc.) Personal safety Child care for infants, toddlers, preschoolers After school care for school age children Summer care for school age children In home care for disabled adult Services for child with disability Substance abuse Getting health and medical care Affordable health insurance Paying for prescribed drugs Getting dental care Getting mental health services

6. What is your age?

What is your age?   18-25 26-35 36-45 46-55 56-65 66+

7. What is your gender?

What is your gender?   male female

8. What is your ethnic group?

What is your ethnic group?   White/ Caucasian African American/ Black Hispanic/ Latino American Indian Asian Multi-racial

9. What is the highest level of education you completed?

What is the highest level of education you completed?   Did not graduate from high school Graduated from high school or earned GED Attended 1-2 years college or technical school Graduated with Associate's degree or two year certifiate Completed 3-4 years of college or technical school Graduated with Bachelor's degree Graduated with a Master's degree or higher

10. What kind of form of transportation do you have?

What kind of form of transportation do you have?   personal vehicle public transit rely on friends rely on family

11. What is your employment status?

What is your employment status?   Full time Part time Seasonal work Self employed Unemployed student Unemployed SSI/ Disability Unemployed by choice (homemaker, etc.) Unemployed- cannot find job Retired Voluteer

12. What is your yearly income?

What is your yearly income?   5-10,000 10-20,000 20-30,000 30-40,000 40,000+

13. Do you have health insurance?

Do you have health insurance?   Yes- but only for myself Yes- but only for my children Yes- for my entire family No- I do not have health insurance

14. Are you the head of the household?

Are you the head of the household?   Yes No

15. Do you own or rent your home?

Do you own or rent your home?   Own Rent

16. How many adults, counting yourself, live in your household?

How many adults, counting yourself, live in your household?   0-3 3-6 6-10 10+

17. How many children (ages birth to 17) live in your household?

How many children (ages birth to 17) live in your household?   0-3 3-6 6-10 10+

18. Is anyone in your house disabled or on public assistance?

Is anyone in your house disabled or on public assistance?   Yes No

19. Do you have children who will be under five years old as of 8/1/2010?

Do you have children who will be under five years old as of 8/1/2010?   Yes No

20. If so, would you be interested in enrolling your child in Head Start?

If so, would you be interested in enrolling your child in Head Start?   Yes No