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Instructions: Please fill out this survey to help the department of public health and community leaders learn about what our community members need to have a better quality of life. The information you provide will be used to put together a large picture of our local community and its needs.  Without your view, we are missing the information that only you can provide on where we as a community are doing a good job, and where we can do much better. This survey should take about 10 minutes for you to complete.
Home life

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* 1. What language(s) do you speak at home? Please select all that apply.

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* 2. Do you have concerns about any of the following safety issues in your neighborhood? Please select all that apply

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* 3. Is the place you live in:

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* 4. Think about the place you live. Do you have problems with any of the following that regularly impact the way you live? Please select all that apply.

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* 5. Please answer the following, as they relate to internet access at your home:

  Yes No  I choose not to answer 
I have high-speed internet/broadband at home
High speed internet is available
I can afford high speed internet
I’m interested in high speed internet
High speed internet is available, but is not reliable

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* 6. Please rate each of the following:

  Excellent Good Fair Poor Don’t Know I choose not to answer
Your city/town as a place to live
Your neighborhood as a place to live
Your city/town as a place to retire
The overall quality of life in your city/town

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* 7. If you were in need of the following services, how accessible are each of them? Please rate each of the following needs in terms of your ability to access.

  Extremely Very Somewhat  Not very Not at all I’m not sure  I choose not to answer
In-home care services
Medical care or assistance
Mental health care or assistance
Dental care or assistance

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* 8. During a typical week, how many hours do you spend:

  None 1-3 hours 4-6 hours 6+ hours I choose not to answer
Helping friends, relatives, or neighbors
Volunteering your time
Talking, visiting with friends/family
Giving care to someone age 18 and up
Receiving help, paid or unpaid (e.g., with shopping, cooking, etc.)
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