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Introduction:

Thank you in advance for taking the time to respond to the questions in this assessment. 
We are requesting your assistance in collecting important data about our community. 
The data collected will help us get a better idea of what the current conditions are in our community and what members of the community believe are the biggest problems and needs. 
This assessment aims to gather information that relates to the health, access to healthcare, housing, education, childcare, economic conditions, transportation, safety, access to food, and other resources and services in our counties (Cherokee, Clay, Graham, and Swain).
The information that you provide will be kept anonymous (no one will know who said what) and will be used to help us develop plans for how to address the issues. 
Your input will also help us to document and justify the need for additional assistance and request funding and other resources that may be available to address the issues that need the most improvement according to you, the members of our Four Square Community. 

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* 1. Todays Date

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* 2. What is the ZIP of your residence?

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* 3. What County do you live in?

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* 4. What is your age range?

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* 5. What is your gender?

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* 6. What is your marital status?

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* 7. Which of the following best represents your race or ethnic heritage?

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* 8. How much school did you complete?

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* 9. Is anyone in your household disabled? ⃝

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* 10. Are you or anyone in your household a veteran?                          ⃝

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* 11. Are there children under 18 living in your home?

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* 12. Are you able to work?

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* 13. What is your employment status?

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* 14. If  you are employed which shift most closely aligns with your work schedule ⃝

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* 15. If you are unemployed are you seeking work?

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* 16. If you are unemployed, please select the reason or reasons why. (Check all that apply) ⃝

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* 17. The following questions relate to housing, homelessness and transportation.
For each question you will check the box that indicates how strongly you agree or disagree with the following statements.

There are enough apartments in my community.

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* 18. There are enough multi-family housing units (designated for families)in my community.

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* 19. There are enough housing options for larger families (over five family members)in my community.

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* 20. There are enough housing options for disabled individuals in my community.

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* 21. There are enough housing options for elderly in my community.

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* 22. There are enough housing options for young adults in my community.

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* 23. Homelessness is a problem in my county.

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* 24. There are programs that help move individuals/ families from homelessness to stability (sheltered, employed, childcare assistance, food, etc) in my county.

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* 25. There are affordable resources to help the elderly repair and maintain their homes.

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* 26. There are affordable resources to help low-income individuals/families to repair and maintain their homes in my county.

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* 27. There are enough assisted living facilities in my county for the elderly and disabled.

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* 28. I can travel easily in my community

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* 29. There are options for transportation if I don’t own a car or cannot drive in my community.

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* 30. There are enough resources for the elderly in my county. (62+) (transportation, housing, food services, other services)

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* 31. There are enough assisted living facilities in my county for the elderly and disabled.

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* 32. I can travel easily in my community

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* 33. There are options for transportation if I don’t own a car or cannot drive in my community.

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* 34. The following questions relate to healthcare, access to care, and health related services. (Check the box that indicates how strongly you agree or disagree with the following statements)

I can easily access quality healthcare in my community.

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* 35. I can afford healthcare in my community

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* 36. I can easily access dental care in my community.

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* 37. I can afford dental care in my community

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* 38. I can access resources for basic screenings and monitoring of my health such as blood pressure, vision checks, diabetes, asthma, etc in my county.

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* 39. I can find and access services for women’s/ men’s reproductive health issues in my county.

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* 40. I can find resources that address substance use disorders (including opiates)in my community.

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* 41. I can find resources that address substance use treatment in my community

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* 42. I can find and access resources to help with quitting tobacco or vape products in my community

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* 43. There are resources to assist with access to mental health services available in my community.

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* 44. I can access services for specialty care (obstetrics, pediatric, wound care, dialysis, cancer treatment, cardiac care, therapy, etc )in my community.

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* 45. The following questions relate to family, childcare, community resources, and social support. (Check the box that indicates how strongly you agree or disagree with the following statements)
Parents/Children

My community is a safe/healthy place to raise children.

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* 46. My community’s public school system provides quality education/related services.

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* 47. My community has reliable childcare service for birth to age three (3).

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* 48. My community has reliable childcare services for 3-5 years of age.

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* 49. My community has adequate access to childcare services for birth to 5 years of age.

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* 50. My community has adequate access to childcare services for after school (birth to 12 years of age)

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* 51. My community has adequate access to childcare services for summer months (birth to 12 years of age)

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* 52. Seniors are connected and socially supported by others in my community. (Friends, family, neighbors, church)

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* 53. Grandparents raising children are able to access support service to aid care in my community. Youth (12- 18)

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* 54. My community is a safe/healthy place for youth.

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* 55. Youth in my community can access affordable resources (recreation, career centers, educational resources, etc.)

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* 56. Alcohol/drug use is a problem among youth in my community.

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* 57. High School dropout rates are an issue in my community.

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* 58. The following questions relate to employment, education, economic opportunity, and income. (Check the box that indicates how strongly you agree or disagree with the following statements)
Economic Opportunity

I can find enough economic opportunities in my community.

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* 59. I can access educational opportunities in my community.

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* 60. There are employment opportunities that pay living wages. (over $15/hour) in my community.

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* 61. I can find enough employment opportunities in my community.

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* 62. Obtaining a legal Driver’s License is an obstacle to employment/ income in my community.

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* 63. There are adequate job prep training opportunities to advance employment/careers in my community

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* 64. I understand how to manage my finances.

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* 65. There are available job training opportunities in my community.

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* 66. There are enough vocational education opportunities in our public schools (Construction, welding, healthcare, plumbing, electrical, etc.)

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* 67. There are enough vocational education opportunities in our community colleges (Construction, welding, healthcare, plumbing, electrical, etc.)

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* 68. There are enough opportunities to learn interview and job-ready skills in my community.

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* 69. The following questions relate to the environment, safety, food security, access to resources.(Check the box that indicates how strongly you agree or disagree with the following statements)
Environmental Safety

My community is safe from crime.

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* 70. My community has adequate access to fire, police and emergency resources

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* 71. I have adequate access to water and septic services in my community.

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* 72. My community has adequate garbage disposal options.

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* 73. Food Access

I can purchase healthy food within 5 miles of my home.

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* 74. I can access affordable food within 5 miles of my home.

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* 75. I can access healthy/affordable food within 15 miles of my home.

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* 76. I always have enough food for my family on a weekly basis.

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* 77. I know how to access food if I do not have money to purchase.

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* 78. Access to Technology Resources

I can easily access internet services in my home.

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* 79. I can easily access internet services at work.

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* 80. I can easily access internet services in other areas in my community.

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* 81. I can afford the cost of internet services in my community.

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* 82. Internet services in my home allow the ability to work/ or access educational resources.

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* 83. I have reliable cell phone service in my community.

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* 84. What is your household yearly income?

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* 85. How long have you lived in your county?

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* 86. Do you have minor children? (under 18)

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* 87. If you have children or other dependents under your care: What is your family situation?

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* 88. Who provides your childcare? (or dependent care)? (Check all that apply)

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* 89. What kind of childcare (dependent care) help do you need?

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* 90. Have you ever lost a job because you didn't have dependable child or dependent care?

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* 91. Who provides care for dependent adult children or adult dependents? (Check all that apply)

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* 92. How many people live where you stay?

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* 93. Do You, or someone in your home, have special needs?