Needs Assessment Survey

Tell us about yourself

This survey will take approximately 15 minutes, and it will be used to help WIAAA determine the most important needs in our community. To learn more about WIAAA, please visit wiaaa.org. Thank you for your participation!

Question Title

* 1. Which Illinois County do you live in?

Bureau

Henderson

Henry

Knox

LaSalle

McDonough

Mercer

Putnam

Rock Island

Warren

Other (please specify)

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* 2. What is your zip code?

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* 3. What is your primary race?

Asian

Black or African American

Middle Eastern or North African

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Other - Please self-describe below:

Question Title

* 4. What is your ethnicity?

Hispanic/ Latino

Not Hispanic/ Latino

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* 5. What is your gender

Man

Woman

Non-Binary

Prefer not to answer

Self-identify (please specify)

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* 6. Which of the following best describes your current relationship status?

Married

Widowed

Divorced

Separated

Cohabiting with a significant other or in a domestic partnership

Single, never married

Prefer not to answer

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* 7. What is your sexual orientation?

Asexual (not attracted to anyone)

Bisexual

Gay

Lesbian

Pansexual

Prefer not to answer

Queer

Straight

None of the above, please specify

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* 8. Using the chart below, is your monthly income above or below the amount listed for your family size?

Above

Below

Prefer not to answer

Use the chart below to answer the question above.

Family Size	Monthly Income
1	$1,823
2	$2,465
3	$3,108
4	$3,750
5	$4,393
6	$5,035
7	$5,678
8	$6,320

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* 9. What is your date of birth?

We are primarily looking for Month and Year. To maintain anonymity you may enter 01 for DD.

Date

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* 10. Do you have Medicare?

Yes