* 1. Which describes you and your relationship to CEFS?

* 2. Are you male or female?

* 3. City of Residency.

* 4. City of Employment. Write N/A if not applicable.

* 5. What is your age?

* 6. What do you feel is the primary cause of unemployment in this community?

* 7. What do you feel is the primary cause of transportation barriers in this community? Check only one.

* 8. What do you feel are the biggest problems facing youth (ages 5-17) in the community? Check up to three answers.

* 9. What do you feel are the biggst problems facing adults in the community? Check up to three.

* 10. Identify which of the following community resources you feel are most needed because there are not enough and/or adequate resources available in the CEFS service are. Indicate whether each listed servies is Most Needed, Somewhat Needed, Not Needed, Don't Know.

  Most needed Somewhat needed Not needed Don't know
Support of caregivers of senior citizens
Support of caregivers of children with disabilities
Parenting skills training
Adult literacy skills training
Adult education/GED classes
Certification/degree programs to help people get jobs
Child care
Affordable housing
Food assistance
Youth programs ages 5 to 12
Teen programs ages 13-18
Health Insurance coverage
Financial aid for people to further their education
Help for people applying for Social Security
Help for people who want to live a healthy lifestyle
Computer skills traiing
Help with budgeting money
Help for people seeking employment
Help for people experience home foreclosure
Help for people who want to start a business
Financial education
Credit Counseling
Home insulation or weatherproofing services
Other home repairs
Removal/repair of condemned or vacant homes
Help for people who are unable to pay their electric/gas bills
help for people who are unable to pay their water bills
Homess services/shelters
healthy relationship programs/classes
Support groups
Nutrition education
Help for people in need of reliable private transportation
help for people to build financial assets; buying a home, starting a business or savings accounts
Free income tax preparation services
Mental Health services
Affordable legal services
Help for people who are unable to pay their rent or mortgage

* 11. 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 gas or electric bill
Inability to pay water bill
Home in foreclosure
Homelessness
Bad credit
Lack of child care or latch key children
Home in need of repairs in order to be safe and efficient
Disability resulting in an inability to work
Domestic violence
Unemployment
Parenting stress
No food
Poor nutrition and unhealthy lifestyle
Stress from providing care to a disabled or ill loved one
Confusion about the Earned Income Tax Credit (EITC) or income tax preparation
Poor reading skills and/or no diploma or High School Equivalency

* 12. Do you have a bank account (checking or savings)?

* 13. Do you presently use check cashing or cash advance services instead of banking services?

* 14. Do you have health insurance coverage?

* 15. Do you have dental insurance coverage?

* 16. Are you in need of an eye exam or glasses but can not afford them?

* 17. In general, do you feel that your are:

* 18. Do you have computer and Internet at home?

* 19. If the answer to the previous question regarding internet access was no, do you have access to a computer at a friend's house or library?

* 20. Select 1 through 10, 1 being worst/least and 10 being best/most.

  1 (worst/least) 2 3 4 5 6 7 8 9 10 (best)
The availability of affordable housing in the community
The housing development in the community
The cost of mortgage and rent in the community
The condition of homes in the community

* 21. What do you think is the single most reason people experience poverty?

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