Please take a moment to fill out this survey, which will help improve our organization and services at Proteus, Inc. This survey will help Proteus understand the needs of your community and design programs that will best serve you. When completed, Proteus staff will collect the survey. Thank you in advance for your time.

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* 1. Which of the following type(s) of organization(s) do you represent (check all that apply)?

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* 2. Which of the following best describes you?

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* 3. Race/Ethnicity (Check all that apply):

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* 4. Age:

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* 5. Gender:

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* 6. What county do you live in?

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* 7. What City/town do you live in:

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* 8. Marital Status:

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* 9. Number of people in your home:

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* 10. How many under 18?

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* 11. Total Annual household income:

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* 12. Which of the following best describes your employment status?

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* 13. If unemployed, what is the reason for not working?

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* 14. What is the highest level of education you have completed?

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* 15. Which of the following best describes your housing status?

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* 16. Which of the following best describes your household composition:

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* 17. Have you received public benefits in the last 2 years?

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* 18. Has anyone in your household received services from Proteus, Inc. within the last 2 years (check all that apply)?

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* 19. Which of the following barriers prevent you from seeking assistance for your basic needs (check all that apply)?

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* 20. Which of the following do you have access to in your home (check all that apply)?

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