Perceived Community Needs

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* 1. What do you feel are the primary  EMPLOYMENT issues in this community? (check a maximum of 3 boxes)

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* 2. What do you feel are the primary   EDUCATION issues in this community? (check a maximum of 3 boxes)

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* 3. What do you feel are the primary  HOUSING issues in this community? (check a maximum of 3 boxes)

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* 4. What do you feel are the primary  NUTRITION issues in this community? (check a maximum of 3 boxes)

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* 5. What do you feel are the primary  INCOME issues in this community? (check a maximum of 3 boxes)

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* 6. What do you feel are the primary  TRANSPORTATION issues in this community? (check a maximum of 3)

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* 7. What do you feel are the primary  HEALTH CARE issues in this community? (check a maximum of 3 boxes)

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* 8. What do you feel are the primary  YOUTH issues in this community? (check a maximum of 3 boxes)

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* 9. What are the most important unmet  CHILDREN'S needs in your community? (check a maximum of 3 boxes)

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* 10. What do you think are the main issues facing  FAMILIES in the community? (check a maximum of 3 boxes)

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* 11. Have you had a need go unmet in the last year?

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* 12. If you answered YES to QUESTION 11, please check all of your needs that went unmet in the past year.

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* 13. Do you feel safe in your community?

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* 14. From the list of services below, choose five (5) that you think are the most needed in the community.  List them in numerical order, with 1 being the most important to you and 5 being the least important.

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* 15. Of the problems listed below, choose five (5) that you feel are the most serious to your community.  List them in numerical order, 1 being the most important to you and 5 being the least

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* 16. If you or someone you know were experiencing one of the following problems, would you know where to get help?

  Yes No
Inability to pay utility bills
Home in foreclosure
Homelessness
Bad credit
Lack of child care
Home in need of repairs
Disability resulting in inability to work
Domestic violence
Unemployment
Parenting stress
No food
Poor nutrition and healthy lifestyle
Drug addiciton
Alcohol addiction
Stress from providing care to a disabled or ill loved one
Free tax preparation assistance for low to moderate income persons
Adult education (GED, etc...)
Suicide prevention

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* 17. Which county do you live in:

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* 18. Please indicate your age bracket:

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* 19. Please indicate your gender:

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* 20. Please indicate your race:

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* 21. What is your ethnicity?

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* 22. Please indicate your current household type:

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* 23. How many people live in your household?

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* 24. Please indicate your TOTAL household income:

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* 25. Please indicate your TOTAL household income 3 years ago:

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* 26. Please indicate your sources of income:

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* 27. Please indicate your highest level of education:

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