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Community Needs Survey
Please answer the following questions by selecting what you feel is the most accurate answer.
OK
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1.
Lack of Affordable Housing in this community is a problem because...(choose one)
(Required.)
High rents
Credit problems
Not enough rental units available
Not enough good quality housing
Too expensive to own
Someone in the household has a criminal record
Other (please specify)
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2.
Unemployment is a problem in this community because... (choose one)
(Required.)
Lack of childcare
Lack of training
Not beneficial to work
Not enough jobs in the county
Lack of transportation to higher wage jobs
Criminal record makes it difficult to get work
Medication that keeps me from being employed
Lack of High School Diploma or GED
Not enough paying jobs to sustain a household
Other (please specify)
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3.
High heating and utility costs are a problem in this community because... (choose one)
(Required.)
Low wages
Landlords not paying
People need help budgeting
Fuel/utility costs are unpredictable
Poorly insulated houses/ old appliances
Other (please specify)
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4.
In your view of the following, which are most important to having a good community? (Choose 3)
(Required.)
Good neighborhood schools
Affordable housing
Safe streets
Neighborhood convenience stores
Recycling available
Buildings in good repair
Good public transportation
Good local library
Responsible neighbors
Plenty of parks/ play areas
Strong neighborhood associations
Good paying jobs locally
Other (please specify)
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5.
Transportation is a problem because... (choose all that apply)
(Required.)
Lack of driver's license
Insurance costs
Gas prices
Bus/ taxi/ train not accessible
Other (please specify)
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6.
Please choose three (3) of the following areas that are most important to you right now:
(Required.)
Having health insurance
Furthering my education
Getting training for a new job
Moving to a better neighborhood
Buying a home
Reliable transportation
Child Care
Getting a job with better wages
Getting a job with benefits
Having affordable housing
Keeping kids in school
Getting help for alcohol or drug addictions
Having enough food
Keeping utility bills current
Having good credit
Parenting skills
Domestic abuse
Reading, writing and math
Other (please specify)
7.
Do all members of your household currently have health insurance?
Yes
No
8.
If no, which members of your household are uninsured?
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9.
Are you concerned about: (choose all that apply)
(Required.)
Prescriptions
Health insurance premiums
Pre-existing medical conditions
Insurance availability/ limitations
Understanding health insurance coverage
Health insurance co-pays
Health insurance coverage
Dental/ vision insurance
Other (please specify)
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10.
Which of the following are missing from your neighborhood? (choose all that apply)
(Required.)
Good neighborhood schools
Affordable housing
Safe streets
Neighborhood convenience stores
Recycling available
Buildings in good repair
Good public transportation
Good local library
Responsible neighbors
Plenty of parks/ play areas
Strong neighborhood associations
Good paying jobs locally
Other (please specify)
11.
We would like to know some general information about you that will help us use the results of this survey. Your identity and answers are confidential and we are not asking for your name.
Culture/Ethnicity (choose all that apply)
American Indian
Asian
Black/ African American
Hispanic/ Latino
Multi-Race
White
Other (please specify)
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12.
Gender: How do you identify?
(Required.)
Man
Non-binary
Woman
Prefer to self-describe, below
Self-describe:
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13.
Age range: (choose one)
(Required.)
17 and under
18 - 23
24 - 44
45 - 54
55 - 69
70 and older
14.
Marital Status: (choose one)
Married
Divorced/ Separated
Never Married
Widowed
Other
15.
Education (last grade completed):
Did not attend school
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
Graduated high school
Some college
Graduated from college
Some graduate school
Completed graduate school
16.
Have you received a:
High School Diploma
GED
Neither
17.
Town of Residence:
Ansonia
Beacon Falls
Bethany
Derby
Milford
Oxford
Orange
Seymour
Shelton
Woodbridge
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18.
Source of Income: (If you have more than one source of income, choose all that apply)
(Required.)
Wages
Public Assistance
Child Support
Social Security
Supplemental Security Income (SSI)
Retirement/ Pension
Unemployment
Other (please specify)
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19.
Gross Household Income Per Month (Before taxes are taken out)
(Required.)
$200 or less
$201 - $400
$401 - $600
$601 - $800
$801 - $1,000
Over $1,000
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20.
Are you a:
(Required.)
Homeowner
Renter
Homeless
Other (please specify)
21.
How much is your monthly rent or mortgage payment?
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22.
Is your monthly rent/ mortgage payment subsidized?
(Required.)
Yes
No
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23.
How many times have you moved in the past year?
(Required.)
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24.
Do you receive SNAP (food stamps) benefits?
(Required.)
Yes
No
25.
Do you believe you have adequate access to get food supplies for your household?
Yes
No
26.
If no, have you accessed a food pantry in the past 12 months?
Yes
No
I do not know of local food pantries
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27.
In general, do you feel that you are:
(Required.)
Better off than one year ago - if so, why?
Worse off than one year ago - if so, why?
About the same - if so, why?
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28.
Is there something you want to do or are determined to do within the next few years?
(Required.)
Yes
No
29.
If yes, please share your goals:
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30.
Are you currently receiving or have received services from TEAM in the last year?
(Required.)
Yes, I have received services in the last year from TEAM
No. I know about TEAM's services and do not require assistance at this time.
No. I do not know what services/programs TEAM has available.
****If interested in learning more, contact TEAM at 203-736-5420.
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