1. Perceived Community Needs

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* 1. What do you feel are the primary EMPLOYMENT issues in this county (check a maximum of 3 boxes)

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* 2. What do you feel are the primary EDUCATION issues in this county (check a maximum of 3 boxes)

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* 3. What do you feel are the primary HOUSING issues in this county (check a maximum of 3 boxes)

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* 4. What do you feel are the primary NUTRITION issues in this county (check a maximum of 3 boxes)

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* 5. What do you feel are the primary INCOME issues in this county (check a maximum of 3 boxes)

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* 6. What do you feel are the primary TRANSPORTATION issues in this county (check a maximum of 3 boxes)

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* 7. What do you feel are the primary HEALTH CARE issues in this county (check a maximum of 3 boxes)

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* 8. What do you feel are the primary YOUTH issues in this county (check a maximum of 3 boxes)

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* 9. Are there unmet needs for childcare services in your county?

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* 10. If you answered YES to QUESTION 9, what do you believe are the primary barriers to obtaining child care services? (check a maximum of 3 boxes)

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* 11. What are the most important unmet CHILDREN'S needs in your county? (check a maximum of 3 boxes)

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* 12. What do you think are the main issues facing FAMILIES in the county? (check a maximum of 3 boxes)

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* 13. What do you think are the main areas that need more attention (check a maximum of 3 boxes)

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* 14. What do you believe are the main factors leading to drug use in the county? (check a maximum of 3 boxes)

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* 15. Have you had a need go unmet in the last year?

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* 16. If you answered YES to QUESTION 15, please check all of your needs that went unmet in the past year.

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* 17. If you or someone you know were experiencing one of the following problems, would you know where to get help?

  Yes No
Inability to pay gas/electric bills
Inability to pay water bills
Home in foreclosure
Homelessness
Bad credit
Lack of child care
Home in need of repairs
Disability resulting in inability to work
Domestic violence
Unemployment
Parenting stress
No food
Poor nutrition and unhealthy lifestyle
Drug addiction
Alcohol addiction
Stress from providing care to a disabled or ill loved one
Free tax preparation assistance (low and moderate income)
Adult education (GED, etc)

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* 18. Have you ever used the 211 telephone information line?

The following questions ask some personal information. We only ask these questions to make sure we get surveys from different demographic groups within the community. Your name is not on the survey, so all of your personal information will remain confidential.

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* 19. Which county do you live in?

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* 20. Which city/town do you live in?

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* 21. Please indicate your age bracket:

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* 22. Please indicate your gender:

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* 23. Please indicate your race:

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* 24. Please indicate ethnicity:

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* 25. Please indicate household type:

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* 26. How many people live in your household?

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* 27. Have you served in the military?

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* 28. Please indicate your TOTAL household income:

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* 29. Please indicate your TOTAL household income – 3 YEARS AGO:

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* 30. Please indicate your source(s) of income: (please check all that apply)

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* 31. Please indicate your highest level of education

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