By completing this survey, you will be helping East Missouri Action Agency (EMAA) gain an understanding of your community and families’ resources and needs. You will be asked to answer survey questions regarding education, employment, income, housing, healthcare, nutrition and transportation. This will take approximately 10-15 minutes to complete.

The benefit of this assessment is that you will be helping organizations in your own community to better understand the community needs, the resources available and the resources that are still needed. The information will help EMAA and our partners work together to address community challenges by providing services, supports and resources that are truly needed. There are no risks to you participating and it is greatly appreciated.
Basic Demographic Information-Please continue to the next page.

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* 1. What is your role in the community? (Please select the best choice that fits your role when completing this survey.)

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* 2. What is your home zip code?

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* 3. What is your age?

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* 4. What gender do you identify as?

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* 5. What race do you identify as? (Choose As Many As Apply)

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* 6. What Ethnicity do you identify with?

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* 7. What is the primary language spoken in your home?

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* 8. Are you a Veteran?

Housing

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* 9. What is your housing situation?

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* 10. How many people are currently living where you reside?

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* 11. Please list the number of individuals by age below.

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* 12. If you are a renter, how much do you pay for monthly rent?

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* 13. If you own your home, how much do you pay in monthly mortgage payment?

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* 14. Do you have homeowners' insurance or renters’ insurance on your belongings

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* 15. Have you experienced any kind of homelessness in the past 12 months?

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* 16. Do you feel that there is a lack of housing in your county?

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* 17. If yes, please check what types are lacking. Check all that apply.

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* 18. What are the barriers that you face when looking for housing? Check all that apply.

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* 19. How much do you pay on average per month for utilities combined? (water, sewer, trash, electric, gas, etc.)

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* 20. Does your home (owned or rental) need extensive repairs?

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* 21. If yes, what type of repairs? Check all that apply.

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* 22.
Does your housing have running water?

Transportation

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* 23. Do you feel that transportation, or lack of, is a barrier to getting and/or keeping a job?

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* 24. Do you have a reliable running vehicle/ personal transportation?

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* 25. What other forms of transportation do you use

Education

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* 26. How far are you or did you go in school?

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* 27. Are there any barriers preventing you from receiving the education you want?

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* 28. If Yes, what were the barriers? Check all that apply.

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* 29. Do you or your children have any of these school/education-related needs? (Check all that apply)

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* 30. What type of skill training would you (or your family members) be interested in to help increase your wages/income?

Employment

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* 31. Are you able to work?

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* 32. What is your employment status (Mark the one that best describes your current situation)?

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* 33. If unemployed, are you actively seeking employment?

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* 34. If employed (seasonal, part-time, full-time), are you searching for a different employment situation?

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* 35. If you are unemployed or underemployed (not satisfied with current employment), please select reasons below: Check all that apply.

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* 36. Have you ever lost a job or couldn’t accept a position due to a lack of affordable or available childcare?

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* 37. Are you able to support your family with the monthly income you receive?

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* 38. Have you ever taken any of the following actions to maintain benefits such as Housing Assistance, SNAP/Food Stamps, TANF, Medicaid etc. (Mark all that apply)

Health

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* 39. Does everyone in your household have health insurance?

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* 40. If No, please indicate reasons. Check all that apply.

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* 41. If yes, what type do you have (if multiple family members with different care, mark all that apply?

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* 42. Which health/behavioral care services have been the hardest for you or your family members to get? Check all that apply.

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* 43. Are you able to get all your prescriptions filled on time and as needed?

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* 44. If sometimes, rarely, or never, please indicate the reason:

Nutrition

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* 45. How far is the nearest food source (Example: Grocery Store, Box Store etc.)?

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* 46. Is there a food bank or pantry available within 10 miles of your home?

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* 47. In the last year, how many times have you used a food bank or pantry to supplement your family’s food needs?

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* 48. How far do you travel for fresh, non-processed, nutritious food?

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* 49. What are the top 3 nutrition issues that impact your family? Mark all that apply.

Income

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* 50. What is the yearly income for your household?

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* 51. What is your source of income? Mark all that applies to your household/family.

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* 52. Please rank your top 5 household expenses (1 being your least expensive to 5 being the greatest cost)

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* 53. Do you have a bank account?

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* 54. Do you have an emergency fund/savings for unexpected emergencies?

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* 55. What is your budgeting style? Check all that apply.

General

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* 56. What EMAA programs have you used in the past?

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* 57. If you have used EMAA programs previously, how satisfied were you with the amount of time it took to receive services or a decision

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* 58. What needs do you see your family, friends, or neighbors experiencing that you believe should be addressed?

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* 59. What strengths or assets do you see in your neighborhood or community?

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* 60. Are you a partner of EMAA or would you like to be?

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* 61. What organization or business are you with?

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* 62. What do you think are the top five key needs of those who are or may be struggling in the community?

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* 63. Of the above, what are the top three community needs or improvements do you think EMAA should focus on? (job creation, affordable housing, accessible and affordable health care, transportation, childcare, education/training, etc.)

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* 64. Is your organization currently addressing any of the needs you identified above? If yes, please specify which are being addressed and how by your organization. What suggestions can you provide on how the needs could be addressed differently and how EMAA can partner with your organization to address those needs together?

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