Low Income Family & Individual Survey 2017

Introduction: 

The purpose of this survey is to help Virginia Legal Aid Society (VLAS) to determine the needs of low income families and individuals in our area and how best to respond to them.

This version of the survey seeks responses from English-speaking low-income residents of our area. The VLAS website, VLAS.org, has an electronic version of this survey for those who prefer to fill it out online, and a version in Spanish. The website also has a shorter survey which we encourage all other community members, community leaders, social service professionals, judges, attorneys and court clerks, and VLAS donors and funding partners to use.

In order to help in solving community and individual problems, we need to know about the kinds of problems you have and about what you do to solve them. We hope that you can take a few minutes to answer some questions for us. Your answers will be kept confidential.
 
April 10 is our last day on which we will accept new survey responses. To thank you for completing our survey, we would like to put your name in a drawing for a $25 gift certificate from Walmart; ten will be awarded, and the drawing will be April 12. After you have finished filling out the survey, please add your contact information on the last page, which will be detached from the rest of survey; we will notify the winners by email and mail the certificates.

BEGINNING

We would like to ask you about problems that may have affected you or someone else in your household. By household, we mean the people with whom you live and share income or expenses.

Section A.  HEALTH CARE

* 1. In the last 12 months, have you or anyone in your household experienced any of the following health problems? Check all that apply.

* 2. In the past 12 months, have you or anyone in your household had any of the following procedures that are intended to prevent future health problems? Check all that apply.

* 3. Where do you go for routine healthcare? Check all that apply.

* 4. In last 12 months, did you or someone in your household have problems with getting routine medical care; emergency treatment; treatment for drug, alcohol, or mental health problems; or nursing home or other long-term care?  Check all that apply.

* 5. Did anything stop you or someone in your household from having procedures to prevent future health problems? Check all that apply.

Section B. MORTGAGE FORECLOSURE

* 6. In the past year, did you or someone in your household experience or almost experience a foreclosure on a home mortgage? Check all that apply:

Section C. CONSUMER LOANS

* 7. During the past twelve months, did you or anyone in your household have problems from a payday loan, a car title loan, or an internet loan?  Check all that apply:

Section D. CONSUMER PURCHASES AND REPAIRS

* 8. During the past twelve months, did anyone in your household spend money to buy something, or to have some work done, then find that you didn’t get what you paid for, and the seller, repair person, or contractor failed to make things right?  Check all that apply:

Section E. IMMIGRATION STATUS

* 9. Were you or anyone in your household born outside the United States, as a citizen of another country, and in the past 12 months had immigration problems? Check all that apply

* 10. If you or someone in your household was born outside the U.S.: during the past twelve months, did you or that person experience harassment or abuse from the following because of your or his/her immigration status?  Check all that apply:

* 11. If yes, what kind of harassment or abuse?

* 12. Did you or anyone in your household have a serious problem because of a difficulty with speaking or reading English?  Check all that apply:

Section F. ADVANCE DIRECTIVES: GUARDIANSHIPS, WILLS, POWERS OF ATTORNEY:

* 13. In the last 12 months, did you or someone in your household have problems getting or using a guardianship, will, power of attorney, or living will?  Check all that apply:

* 14. If someone had a problem with one of these, please check the age of the person:

Section G. EMPLOYMENT

* 15. In the past 12 months, did you or someone in your household have problems with employment?  Check all that apply:

Section H. RENTAL HOUSING

* 16. In the past 12 months, did you live in a place that you were renting from someone else, and have any of the following problems? Check all that apply:

Section I. FAMILY

* 17. In the past 12 months, did you or someone in your household have problems from a family matter such as the break-up of a marriage or live-in relationship?  Check all that apply:

Section J. ABUSE

* 18. In the past 12 months, did you or someone in your household have problems with one of the following forms of abuse? Check all that apply:

* 19. If there was abuse, check the age and gender of the person(s) abused:

Section K. PUBLIC EDUCATION

* 20. In the past 12 months, did you or someone in your household have problems in getting services from a public school or being able to attend a public school? Check all that apply:

Section L. BENEFITS

 

* 21. In the past 12 months, did you or someone in your household have problems with any of the following public or private benefits? Check all that apply:

* 22. In the past year, did you or someone in your household have problems with getting insurance you needed like health, life, automobile, homeowner’s, or renter’s insurance?  Check all that apply:

Section M. ACTION TAKEN TO RESOLVE PROBLEMS

* 23. For the problems above that bothered you the most, what, if anything, did you do? Check all that apply:

* 24. If you answered "did nothing", why did you choose to do nothing? Check all that apply:

* 25. How satisfied were you with the results? Check one:

Section N.  ABOUT YOU:

* 26. Where does your age fall within the following ranges?

* 27. Gender:

* 29. How many of your household members are:

* 30. Is this a single parent household?

* 31. Please check the income category that most closely describes your household income in the last 12 months:

* 32. How often do you use the Internet for information? Check one:

* 33. How often do you use email? Check one:

* 34. When you do use the Internet or check email, how are you most likely to get access? Check all that apply

* 35. Finally, please name the county or city where you live:

Thank you very much for your assistance.  We appreciate the time you took to answer these questions.  If you would like additional information about Virginia Legal Aid Society,, please call 1-866-534-5243 (866-LEGL-AID), or visit our website, www.vlas.org.

If you would like additional information about health insurance help from Enroll Virginia please call 1-888-392-5132 or visit our website www.enrollva.org
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