Question Title

1. Are you recieivng services or have you recieved services from our agency or its programs in the past 12 months?

Question Title

2. How many people live in your household?

Question Title

3. What is your sex?

Question Title

4. What is the primary language spoken in your household?

Question Title

5. Are you Hispanic, Latino, or Spanish origin?

Question Title

6. What is your age?

Question Title

7. What are the ages of the other people living in your home?

  1 2 3 4 5 6 7 8 9+
How many are age 0-3?
How many are age 4?
How many are age 5?
How many are age 6-11?
How many are age 12-17?
How many are age 18-24?
How many are age 25-55?
How many are age 56-64?
How many are age 65-74?
How many are age 75 and over?

Question Title

8. What is your race?

Question Title

9. Where do you live? Please enter your zip code below.

Question Title

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

Question Title

11. What have been your household's top THREE needs within the past 12 months? Check 3 that apply.

Question Title

12. Check ALL the services you or someone in your household needed but did NOT receive within the past 12 months. Check all that apply.

Question Title

13. If you needed services, but didn't get them, what was the reason?

Question Title

14. How did you hear about our agency? Check all that apply.

Question Title

15. Which of the following do you or other members in your household use?

Question Title

16. What is your primary mode of transportation?

Question Title

17. In the past 12 months, has lack of transporation been a problem for your household?

Question Title

18. In the past 12 months, has anyone in your household experienced any of the following challenges with transportation?

Question Title

19. How many people in your home are employed?

  1 2 3 4 5 6+
Number of people Full-Time
Numer of people Part-Time
Number of people Seasonal
Number of people Not Employed

Question Title

20. For the adults (18 years or older) in your household who are NOT employed, please indicate why they do not work. Check all that apply.

Question Title

21. What income or benefits do you or anyone living in your household have? Check all the apply. 

Question Title

22. In the last 12 months, what was your estimated annual household income? (Please include all sources of income from the previous questions.)

Question Title

23. Do you or does anyone in your household have a benefit package through work (health insurance, etc.)

Question Title

24. In the past 12 months, have you or anyone in your household experienced any of the following financial situations? Check all that apply.

Question Title

25. What is your housing status?

Question Title

26. Which of the following best describes your home?

Question Title

27. Which of the following best desribes the consition of your home? Check all that apply.

Question Title

28. If you rent your place, check the utilities that are included in your rent:

Question Title

29. If you do not own a home, what prevents you from buying one? Check all that apply.

Question Title

30. Are you at risk of becoming homeless?

Question Title

31. If you are at risk of becoming homeless, what are the reasons? Check all that apply:

Question Title

32. Have you experienced any of the following problems related to housing in the past 12 months? Check all that apply:

Question Title

33. In the past 12 months, have you or has anyone in your household skipped or cut the size of a meal because there was not enough food?

Question Title

34. If yes, how often have you or has anyone in your household skipper or cut the size of a meal?

Question Title

35. Are you able to afford enough formula for your infant?

Question Title

36. In the past 12 months, have you or has anyone in your household used any of the following food assistance services? Check all that apply:

Question Title

37. In the past 12 months, have you or anyone in your household has to choose between buying foor or paying a bill to meet other basic needs (housing, heat, etc.)

Question Title

38. In the past 12 months, have you or has any member of your household not been able to get needed medical, dental or mental health care; or perscription medications? Please specify:

Question Title

39. If you or your family members did not get the care you needed, please indicate the main reasons. Check all that apply:

Question Title

40. How many children under the age of 17 in your household have no health insurance?

Question Title

41. How many adults 18 years and older in your household have no health insurance?

Question Title

42. Did you buy health insurance through the NYS Health Marketplace (as part of the affordable care act)?

Question Title

43. Is your child or are your children up to date on their scheduled immunizations?

Question Title

44. Do you feel safe in your neighborhood?

Question Title

45. Do you have a child under age 18 with a disability in your household?

Question Title

46. Do you have an adult 18 years or older with a disabiilty in your household?

Question Title

47. If you do not have at least one child under the age of 18 in your household, please skip to section 10-Open Ended Questions by selecting an option below.

Question Title

48. What do you currently use to meet your child care needs? Check all that apply:

Question Title

49. What time of day do you need child care? Check all that apply:

Question Title

50. Have you ever used a day care center or a registered child care provider?

Question Title

51. If no, why not? Check all that apply:

Question Title

52. How do you meet the cost of your child care?

Question Title

53. Have any of the following been an issue for concern for any youth (under 18) in your household in the past 12 months? Check all that apply:

Question Title

54. Are you a grandparent or other relative raising children other than your own?

Question Title

55. If yes, please indicate the primary reason for care.

Question Title

56. Please add anything you would like our agency to know.

Question Title

57. What is one services that has helped you or someone in your household the most within the past 12 months?

0 of 57 answered
 

T