By completing this survey, you will help towards research of understanding families' resources and needs.  You will be asked to answer survey questions that include education, employment, housing, healthcare and other basic needs.  This will take approxiamtely 15 - 20 minutes of your time.
 
The benefit of this research is that you will be helping the organizations in your community to better understand our community needs, the resources available and the services that are still needed.  This information will help us to work together to address services that are needed the most.  There are no risks to you for participating in this study, and no penalty for not participating.


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1. Today's Date: (Required.)

Date

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2. What is your age? (Required.)

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3. How far did you go in School? (Required.)

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4. Below is a list of agencies.  Please select any who are providing you and your family with help?

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5. Are you able to work? (Required.)

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6. What is your employment status? (Required.)

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7. If Unemployed, are you currently looking for work?

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8. If you are unemployed, please select the reason(s) why below:

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9. Would you like help with these job related activities? (Check all that apply) (Required.)

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10. Do you have reliable telephone access? (Required.)

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11. Do you have access to the Internet? (Required.)


If No is selected, then SKIP the next question.

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12. Where do you usually use the internet?  (Check all that apply)

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13. What is your Zip code? (Required.)

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14. In what town do you usually stay? (Required.)

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15. What is your housing status? (Required.)

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16. Which of the following best represents your racial or ethnic heritage? (Required.)

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17. What language do you speak at home? (Required.)

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18. What is your marital status? (Required.)

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19. Do you have minor children? (under 18) (Required.)


If No is selected, then SKIP the next question.

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20. Are you your child(ren)'s primary caretaker?

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21. If you have children or other dependents under your care:  What is your family situation?

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22. Who provides your childcare? (or dependent care)? (Check all that apply)



If "Self" is selected, then SKIP the next question.

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23. Is your childcare (dependent care) provider dependable?

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24. Do you need different childcare (dependent care) help?

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25. What kind of childcare (dependent care) help do you need?

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26. Have you ever lost a job because you didn't have dependable child or dependent care?

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27. Are you caring for adult children or adult dependents including seniors?  (Due to mental or physical disability)


If No is selected, then SKIP the next question.

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28. Who provides care for the adult children or adult dependents?  (Check all that apply)

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29. How many people live where you stay? (Required.)

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30. Using the answer from previous question, please select the appropriate number of household members to determine Income level? (Required.)

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31. Is your household income "More than" or "Less than" the Income level selected for the number of household members? (Required.)

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32. Which of these monthly bills do you have? (Check all that apply) (Required.)

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33. What types of income do you have? (Check all that apply) (Required.)

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34. Tell me if you or a household member receive any of these types of assistance? (Check all that apply) (Required.)

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35. Do You, or someone in your home have special needs? (Required.)


If No is selected, then SKIP the next question.

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36. Do you have any of these School/Education related needs?  (Check all that apply)

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37. In the past 24 months, has your child had to transfer schools because you moved? (Required.)

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38. Do you have any of the following housing related needs? (Check all that apply) (Required.)

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39. Do you need any of the following transportation related help?  (Check all that apply) (Required.)

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40. Have you ever lost a job (or not been able to accept a job offer) because of transportation issues? (Required.)

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41. Are you in need of help with any of these things:  (Check all that apply) (Required.)

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42. Where do you usually get your food? (Required.)

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43. Do you need information on how to cook food for any of these special diets?  (Check all that apply) (Required.)

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44. Do you need information on food nutrition? (Required.)

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45. Do you need to know how to store food so it will last longer? (Required.)

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46. Do you or someone in your household have any of these healthcare needs?  (Check all that apply) (Required.)

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47. Do you have health insurance or other health care coverage? (Required.)

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48. Are there others in your household who are uninsured? (Required.)

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49. If you have health insurance, who provides your health insurance?

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50. Do you have any of these financial needs or problems?  (Check all that apply) (Required.)

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51. Are you a US veteran? (Required.)


If No is selected, then SKIP to the LAST question.

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52. If you are a US veteran, are you receiving veteran's benefits?

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53. If you are not receiving veteran's benefits, do you need help getting them?

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54. If you are a veteran or dependent, do you need assistance with any of the following?  (Check all that apply)

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55. What have we not asked you about that you feel is important?

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