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ACCORD Community Member Survey
1.
Are you recieivng services or have you recieved services from our agency or its programs in the past 12 months?
Yes
No
2.
How many people live in your household?
1
2
3
4
5
6
7
8
3.
What is your sex?
Male
Female
4.
What is the primary language spoken in your household?
English
Spanish
Other (please specify)
5.
Are you Hispanic, Latino, or Spanish origin?
No; Not Hispanic, Latio, or Spanish origin
Yes; Mexician, Mexican American, or Chicano
Yes; another HIspanic, Latino, or Spanish origin- (please specify)
6.
What is your age?
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?
1
2
3
4
5
6
7
8
9+
How many are age 4?
1
2
3
4
5
6
7
8
9+
How many are age 5?
1
2
3
4
5
6
7
8
9+
How many are age 6-11?
1
2
3
4
5
6
7
8
9+
How many are age 12-17?
1
2
3
4
5
6
7
8
9+
How many are age 18-24?
1
2
3
4
5
6
7
8
9+
How many are age 25-55?
1
2
3
4
5
6
7
8
9+
How many are age 56-64?
1
2
3
4
5
6
7
8
9+
How many are age 65-74?
1
2
3
4
5
6
7
8
9+
How many are age 75 and over?
1
2
3
4
5
6
7
8
9+
8.
What is your race?
White or Caucasian
Black or African American
Asian or Asian American
American Indian or Alaska Native
Another race
Other (please specify)
9.
Where do you live? Please enter your zip code below.
10.
What is the highest level of education you have completed?
Less than high school degree
High school diploma/HSE/GED
Trade School
Some College
Associate's Degree
Bachelor's Degree
Graduate or professional degree
11.
What have been your household's top THREE needs within the past 12 months? Check 3 that apply.
Adult Education/Literacy
Child Care
Dental Care
Domestive Violence Assistance
Family Counseling
Financial Assistance
Food Assistance
Health Care
Heating/Utility Assistance
Job Skills/Employment Training
Mental Health Services
Parenting Education
Safe, Affordable Housing
Safety/Crime Prevention
Senior Citizens Services
Substance Abuse Assistance
Summer Recreation Programs
Transportation
Veteran's Services
Youth Programs
None of the above
Other (please specify)
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.
Adult Education/Literacy
Child Care
Dental Care
Domestive Violence Assistance
Family Counseling
Financial Assistance
Food Assistance
Health Care
Heating/Utility Assistance
Job Skills/Employment Training
Mental Health Services
Parenting Education
Safe, Affordable Housing
Safety/Crime Prevention
Senior Citizens Services
Substance Abuse Assistance
Summer Recreation Programs
Transportation
Veteran's Services
Youth Programs
None of the above
Other (please specify)
13.
If you needed services, but didn't get them, what was the reason?
I was unable to get to the services location
The service I needed was not available
I didn't know about the service
Does not apply
Other (please specify)
14.
How did you hear about our agency? Check all that apply.
I visited the agency website
I have seen information about the agency as various locations throughout the county
I have read information about the agency in local newspapers
I was referred to the agency
This survey is my first time hearing about the agency
Word of mouth
ACCORD's newsletter, "The CORD"
Other (please specify)
15.
Which of the following do you or other members in your household use?
Cable TV of satellite dish
Cell phone on contract
Email
Free cell phone (SafeLink, Assurance, etc.)
Internet
Landline phone
Newspaper
Pre-paid or "pay as you go" cell phone
Social Media (Facebook, Instagram, etc.)
16.
What is your primary mode of transportation?
Bicycle
Bus/Subway
Car
Car Pool/ Ride Share
Motorcycle
Ride with Family/Friends
Walking
Other (please specify)
17.
In the past 12 months, has lack of transporation been a problem for your household?
Yes
No
18.
In the past 12 months, has anyone in your household experienced any of the following challenges with transportation?
Inability to afford gas
Inability to afford car repairs
No access to a car
No car insurance
No driver's license or license suspended
Unable to use the public bus system
Public transportation not accessible
Public transportation is too expensive
Unable to use the subway
19.
How many people in your home are employed?
1
2
3
4
5
6+
Number of people Full-Time
1
2
3
4
5
6+
Numer of people Part-Time
1
2
3
4
5
6+
Number of people Seasonal
1
2
3
4
5
6+
Number of people Not Employed
1
2
3
4
5
6+
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.
Caring for children
Caring for elderly relatives
Criminal History
Drug/Alcohol problems
Lack of necessary job skills
Mental Health Problems
No high school diploma/GED/HSE
Physical disability/illness
Retired
Student
Other (please specify)
21.
What income or benefits do you or anyone living in your household have? Check all the apply.
Child support
Heating Energy Assitance Program (HEAP)
Housing subsidy (ex. Section 8)
Salary from job
New York State Disability
Pension
Public assistance (DSS Emergency or Safety Net)
Retirement Pension
Self-Employment (including babysitting, cleaning, etc.)
SNAP (food stamps)
Social Security
Social Security Disability (SSD)
Social Security Disability (SSI)
TANF (DSS Assistance)
Unemployment Insurance
VA Pension
Women, Infants, and Children (WIC)
Workers' Compensation
None of the above
Other (please specify)
22.
In the last 12 months, what was your estimated annual household income? (Please include all sources of income from the previous questions.)
Under $10,000
Between $10,010 and $20,000
Between $20,001 and $30,000
Between $30,001 and $40,000
Between $40,001 and $50,000
Between $50,001 and $60,000
Between $60,001 and $70,000
Between $70,001 and $80,000
More than $80,001
23.
Do you or does anyone in your household have a benefit package through work (health insurance, etc.)
Yes
No
Does not apply
24.
In the past 12 months, have you or anyone in your household experienced any of the following financial situations? Check all that apply.
Borrowed money from friends/family for bills
Could not pay child care bills
Fell behind on rent or mortgage payments
Had property (car, appliance, or furniture) repossessed
Had utilities (water, heat, telephone, cell phone, or electric) shut off
Pawned or sold valuables to pay off bills
Used a check cashing service
Used rent-to-own services
None of the above
25.
What is your housing status?
I own my place
I rent my place
I live in subsidized housing
I live with friends
I live with parents or other relatives
Other (please specify)
26.
Which of the following best describes your home?
Apartment
Single-family home
Multi-family house
Trailer/Mobile Home
Transitional group housing
Other (please specify)
27.
Which of the following best desribes the consition of your home? Check all that apply.
It is in good shape, no repairs needed
It needs minor repairs
It needs major repairs
It is in such poor condition that it is unsafe
It needs disability access improvements (wheelchair, ramp, wider doorways, etc.)
In needs weatherization measures (insulation, weatherstrip, caulk, etc.)
Does not apply
28.
If you rent your place, check the utilities that are included in your rent:
Heat
Electric
Water
None of the above are included
Does not apply- I do not rent
29.
If you do not own a home, what prevents you from buying one? Check all that apply.
I choose not to own a home
I cannot afford monthly payments
I cannot afford a down payment
I do not have good credit
I will not live in this area very long
The home-buying process is too complicated
Does not apply, I own my own place
Other (please specify)
30.
Are you at risk of becoming homeless?
Yes
No
31.
If you are at risk of becoming homeless, what are the reasons? Check all that apply:
I cannot afford mortgage/rent costs
I cannot afford to pay my bills (electricity, heat, etc.)
I cannot afford to pay taxes on my property
I am unemployed
The place I live in is in poor condition/owner does not make repairs
I am being evicted
I have medical health or disability issues
Other (please specify)
32.
Have you experienced any of the following problems related to housing in the past 12 months? Check all that apply:
I have bad credit
I can't afford needed repairs
I can't afford the electric bill
I can't afford the heat bill
I can't find affordable housing
My physical disability makes it hard to find housing
I was evicted
I am homeless
My house was foreclosed
I lost my job
I moved to another place
I was threatened with eviction
None of the above
Other (please specify)
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?
Yes
No
34.
If yes, how often have you or has anyone in your household skipper or cut the size of a meal?
Daily
Weekly
Monthly
Does not apply, I have not skipped or cut the size of a meal
35.
Are you able to afford enough formula for your infant?
Yes
No
I do not have an infant
I do not use formula
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:
Backpack program
Food Pantry
School breakfast/lunch program
SNAP (food stamps)
Summer meals for kids
Women, Infants, and Children (WIC)
None of the above
Other (please specify)
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.)
Yes
No
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:
Medical Care
Dental Care
Mental Health Care
Presrciption Drugs
None of the above
39.
If you or your family members did not get the care you needed, please indicate the main reasons. Check all that apply:
It costs too much
Have no way to get to or from the appointment
Have no insurance
Nervous/afraid to go
Did not know where to go
It takes too many days to get an appointment
Could not get child care
Cannot afford prescriptions
The doctor does not accept new patients
Does not apply
Other (please specify)
40.
How many children under the age of 17 in your household have no health insurance?
0
1
2
3
4
5+
41.
How many adults 18 years and older in your household have no health insurance?
0
1
2
3
4
5+
42.
Did you buy health insurance through the NYS Health Marketplace (as part of the affordable care act)?
Yes
No
I do not know
43.
Is your child or are your children up to date on their scheduled immunizations?
Yes
No
Does not apply- I don't have children
44.
Do you feel safe in your neighborhood?
Yes
No
45.
Do you have a child under age 18 with a disability in your household?
Yes
No
46.
Do you have an adult 18 years or older with a disabiilty in your household?
Yes
No
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.
I DO NOT have children under the age of 18 in my household
I DO have children under the age of 18 in my household.
48.
What do you currently use to meet your child care needs? Check all that apply:
After school program
Children are old enough to be left on their own
Day care center
Head Start/Early Head Start
Informal/Unregistered provider/babysitter
Parent, family/friends, or neighbors
Pre-Kindergarten/Preschool
Registered/licensed child care provider
49.
What time of day do you need child care? Check all that apply:
Daytime
Before/After School
Evening
Weekends
Does not apply
50.
Have you ever used a day care center or a registered child care provider?
Yes
No
Does not apply
51.
If no, why not? Check all that apply:
I cannot afford it
Infant care was not available
Evening/night-time slots were not available
I do not trust day care centers
I did not have transportation
The quality of the day care center was not good
Weekend slots were not available
Other (please specify)
52.
How do you meet the cost of your child care?
Subsidy
Self-pay
Does not apply
Other (please specify)
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:
Bullying
Drug Abuse
Eating disorders
Emotional of behavioral problems
Sexual activity
Teenage pregnancy
Violence
None of the above
Other (please specify)
54.
Are you a grandparent or other relative raising children other than your own?
Yes
No
55.
If yes, please indicate the primary reason for care.
Mental illness
Substance Abuse
Someone is in jail or prison
Does not apply
Other (please specify)
56.
Please add anything you would like our agency to know.
57.
What is one services that has helped you or someone in your household the most within the past 12 months?
Current Progress,
0 of 57 answered