Family Survey

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* 4. What is your race?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multi-race (two or more of the previous)

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* 5. What is your ethnicity?

Hispanic, Latino or Spanish Origins

Not Hispanic, Latino or Spanish Origins

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

English

Spanish

Other (please specify)

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* 7. What your annual household income?

Under $15,000

Between $15,000 and $29,999

Between $30,000 and $49,999

Between $50,000 and $74,999

Between $75,000 and $99,999

Between $100,000 and $150,000

Over $150,000

Decline to answer

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* 8. What type of income does your household receive?
(Check all that apply)

Income from employment only

Income from employment and other sources (TANF, SSI, SSDI, VA, Workers Compensation, Social Security, Pension, Alimony, Child Support, Unemployment).

Only other sources (TANF, SSI, SSDI, VA, Workers Compensation, Retirement from Social Security, Pension, Alimony, Child Support, Unemployment).

Income from employment and Non-Cash Benefits (SNAP-food stamps, WIC, HUD, LIHEAP)

Non Cash Benefits Only (SNAP-food stamps, WIC, HUD, LIHEAP)

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* 9. What is your household type?

Single person

Two adults, no children

Single parent, female

Single parent, male

Two parent household

Non-related adults with children

Multigenerational household (grandparents, parents, children)

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* 10. What is your household size?

Single person

Two

Three

Four

Five

Six or more

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* 11. What is your education level?

Grades 0-8

Grades 9-12/Non-Graduate

High School Graduate/Equivalency Diploma

12th Grade + Some Post-Secondary

2 or 4 years College Graduate

A graduate of Other Post-Secondary School

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* 12. What is your military status?

Veteran

Active Military

N/A

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* 13. If you are employed, please select the following that best describes your situation.

I am employed full time, with benefits, such as insurance or paid time off.

I am employed full time, but do not have benefits.

I am employed part time, or work in seasonal, temporary jobs.

I am employed and work more than one job.

N/A

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* 14. If you are not employed, please select the following that best describes your situation. Check as many that apply:

I do not have childcare during work hours.

I do not have transportation to get to where I need to go.

I don’t have the necessary skills for jobs in my area.

I have unmet health needs that prevent me from working.

There are jobs in my area, but they don’t pay enough for me to live off of. There are no jobs in my area.

How long has it been since you last worked?

I choose not to work.

N/A

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* 15. Pick what best describes your housing situation.

I own my own home.

I rent the home of my choosing without housing assistance or subsidy.

I rent and receive section 8 or other housing assistance.

I don’t have a place of my own, so I stay with family or friends.

I live in a shelter or other type of transitional housing.

I live in a motel/hotel/RV/car.

I am homeless-I don’t know where I will sleep tonight.

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* 16. When it comes to housing costs, check all that apply:

I have money left over to live off of after I pay my rent or mortgage.

I do not have money for other basic needs after I pay my rent or mortgage.

I have high utility bills.

I do not feel safe where I live.

My home needs repair (roof, plumbing, windows, foundation, etc.) that I cannot afford.

My landlord does not respond to my requests to repair my home.

I have had to ask for assistance with housing costs (rent, mortgage, utilities) at least once in the past year.

I am facing eviction or foreclosure

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* 17. When it comes to education, please select as many that apply:

I am not interested in pursuing higher education.

When I am ready to seek higher education, I should not have any problems doing so.

I want to pursue higher education, but I cannot afford it.

I want to pursue higher education, but I do not have childcare.

I want to pursue higher education, but I cannot I do not have transportation. I want to pursue higher education, but I struggle with reading and writing.

I want to pursue higher education, but English is not my first language.

I want to pursue higher education, but Iack computer skills.

The training I want is not offered where I live

My work schedule does not allow me the time to go to school

Other (please specify)

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* 18. When it comes to health, select all that apply:

I can afford to meet my health needs (physical, mental, dental, etc.).

There are places I could go to get care, but I cannot afford to go.

There are places I could go to get care, but I don’t have transportation to get there.

There are no health providers in my community that offer the care I need. There are no places for me to go to get the care I need.

I have prescriptions that I cannot afford to fill.

I have Health insurance pick the ones that apply: (Medicaid, Medicare, private employer, market place)

I do not have health insurance.

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* 19. When it comes to transportation, please select all that apply:

I have transportation to get to where I need to go.

Many of my needs go unmet b/c I don’t have transportation.

I don’t have a driver’s license.

I cannot afford car insurance.

My community has public transportation that I can access

My community has public transportation, but does not run where I live.

My community has public transportation, but I cannot afford to use it.

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* 20. When it comes to Income and asset building, please select all that apply:

I have a checking account.

I have a savings account.

I can get credit or a low-interest rate loan if I need it.

I know where I can file my taxes for free or low cost.

My community has places I can go to learn how to manage my money.

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* 21. When it comes to nutrition, please select all that apply:

I can afford, without assistance, to buy healthy foods to feed myself and my family.

I can afford to feed myself and my family b/c I get help with food stamps.

Even though I receive food stamps, some months I still run out of money to buy food.

There are no grocery stores within a mile of my house.

There are no places for me to go to get emergency food, like a food bank.

Food banks are available, but they do not have fresh fruits or vegetables and often do not offer complete meal options.

There are farmers markets and other places to get food in my neighborhood, but I don’t have transportation to get there.

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* 22. If you have a car, please select all that apply:

I can afford to put gas in my car when I need to.

I can afford maintenance on my car (oil change, registration, tune-ups).

I drive, but without a license and/or insurance.

N/A

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* 23. My community offers the following:

Opportunities to develop leadership skills

Opportunities to obtain citizenship

Community groups or neighborhood associations you can join

Opportunities to join advisory boards or other community groups Opportunities for you to register and exercise your right to vote

N/A

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* 24. What else do you think we at Blue Ridge Community Action should know so that we can help individuals and families achieve economic security and create strong, thriving communities?

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* 25. If you are currently struggling with any of the things on this survey, wherein your community are you likely to go for help?

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* 26. If you have received services from our agency in the past, which services did you receive?

We appreciate your time in completing this survey!

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* 27. If you would like to be entered into a drawing to win a gift card (One winner per county?) please provide us with the following information:

Name

Address

Phone Number

Family Survey

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* 1. In which county do you live?

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* 2. What is your gender?

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* 3. What is your age?

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* 4. What is your race?

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* 5. What is your ethnicity?

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

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* 7. What your annual household income?

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* 8. What type of income does your household receive? (Check all that apply)

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* 9. What is your household type?

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* 10. What is your household size?

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* 11. What is your education level?

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* 12. What is your military status?

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* 13. If you are employed, please select the following that best describes your situation.

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* 14. If you are not employed, please select the following that best describes your situation. Check as many that apply:

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* 15. Pick what best describes your housing situation.

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* 16. When it comes to housing costs, check all that apply:

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* 17. When it comes to education, please select as many that apply:

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* 18. When it comes to health, select all that apply:

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* 19. When it comes to transportation, please select all that apply:

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* 20. When it comes to Income and asset building, please select all that apply:

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* 21. When it comes to nutrition, please select all that apply:

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* 22. If you have a car, please select all that apply:

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* 23. My community offers the following:

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* 24. What else do you think we at Blue Ridge Community Action should know so that we can help individuals and families achieve economic security and create strong, thriving communities?

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* 25. If you are currently struggling with any of the things on this survey, wherein your community are you likely to go for help?

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* 26. If you have received services from our agency in the past, which services did you receive?

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* 27. If you would like to be entered into a drawing to win a gift card (One winner per county?) please provide us with the following information:

* 8. What type of income does your household receive?
(Check all that apply)