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* 1. Are you recieivng services or have you recieved services from our agency or its programs in the past 12 months?

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* 2. How many people live in your household?

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* 3. Which of the following most accurately describes you? Choose as many as you like.

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* 4. What is the primary language spoken in your household?

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* 5. Are you Hispanic, Latino, or Spanish origin?

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* 6. What is your race?

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* 7. What is your age?

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* 8. What are the ages of the other people living in your home?

  1 2 3 4 5 6 7 8 9+
How many are age 0-3?
How many are age 4?
How many are age 5?
How many are age 6-11?
How many are age 12-17?
How many are age 18-24?
How many are age 25-55?
How many are age 56-64?
How many are age 65-74?
How many are age 75 and over?

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* 9. Where do you live? Please enter your zip code below.

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

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* 11. What have been your household's top THREE needs within the past 12 months? Check 3 that apply.

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* 12. Check ALL the services you or someone in your household needed but did NOT receive within the past 12 months. Check all that apply.

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* 13. If you needed services, but didn't get them, what was the reason?

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* 14. How did you hear about our agency? Check all that apply.

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* 15. Which of the following do you or other members in your household use?

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* 16. What is your PRIMARY mode of transportation?

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* 17. In the past 12 months, has lack of transporation been a problem for your household?

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* 18. In the past 12 months, has anyone in your household experienced any of the following challenges with transportation?

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* 19. How many people in your home are employed?

  1 2 3 4 5 6+
Number of people Full-Time
Numer of people Part-Time
Number of people Seasonal
Number of people Not Employed

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* 20. For the adults (18 years or older) in your household who are NOT employed, please indicate why they do not work. Check all that apply.

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* 21. What income or benefits do you or anyone living in your household have? Check all that apply.

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* 22. In the last 12 months, what was your estimated annual household income? (Please include all sources of income from the previous questions.)

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* 23. Do you or does anyone in your household have a benefit package through work (health insurance, etc.)

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* 24. In the past 12 months, have you or anyone in your household experienced any of the following financial situations? Check all that apply.

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* 25. What is your housing status?

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* 26. Which of the following best describes your home?

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* 27. Which of the following best describes the condition of your home? Check all that apply.

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* 28. If you rent your place, check the utilities that are included in your rent:

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* 29. If you do not own a home, what prevents you from buying one? Check all that apply.

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* 30. Are you at risk of becoming homeless?

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* 31. If you are at risk of becoming homeless, what are the reasons? Check all that apply:

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* 32. Have you experienced any of the following problems related to housing in the past 12 months? Check all that apply:

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* 33. In the past 12 months, have you or has anyone in your household skipped or cut the size of a meal because there was not enough food?

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* 34. If yes, how often have you or has anyone in your household skipper or cut the size of a meal?

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* 35. Are you able to afford enough formula for your infant?

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* 36. In the past 12 months, have you or has anyone in your household used any of the following food assistance services? Check all that apply:

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* 37. In the past 12 months, have you or anyone in your household had to choose between buying food or paying a bill to meet other basic needs (housing, heat, etc.)

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* 38. In the past 12 months, have you or has any member of your household not been able to get needed medical, dental or mental health care; or perscription medications? Please specify:

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* 39. If you or your family members did not get the care you needed, please indicate the main reasons. Check all that apply:

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* 40. How many children under the age of 17 in your household have no health insurance?

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* 41. How many adults 18 years and older in your household have no health insurance?

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* 42. Did you buy health insurance through the NYS Health Marketplace (as part of the affordable care act)?

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* 43. Is your child or are your children up to date on their scheduled immunizations?

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* 44. Do you feel safe in your neighborhood?

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* 45. Do you have a child under age 18 with a disability in your household?

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* 46. Do you have an adult 18 years or older with a disabiilty in your household?

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* 47. If you do not have at least one child under the age of 18 in your household, please skip to section 10-Open Ended Questions by selecting an option below.

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* 48. What do you currently use to meet your child care needs? Check all that apply:

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* 49. What time of day do you need child care? Check all that apply:

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* 50. Have you ever used a day care center or a registered child care provider?

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* 51. If no, why not? Check all that apply:

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* 52. How do you meet the cost of your child care?

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* 53. Have any of the following been an issue for concern for any youth (under 18) in your household in the past 12 months? Check all that apply:

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* 54. Are you a grandparent or other relative raising children other than your own?

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* 55. If yes, please indicate the primary reason for care.

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* 56. Please add anything you would like our agency to know.

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* 57. What is one services that has helped you or someone in your household the most within the past 12 months?

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