* 1. The zip code where you live: Medina County  (If you live in Wayne County, see question #2)

* 2. The zip code where you live:  Wayne County  (If you live in Medina County, see question #1)

* 3. Your gender

* 4. Your marital status

* 5. Highest level of education completed

* 6. Which best describes your racial or ethnic background (check all that apply)

* 7. What is your current age

* 8. Total number of persons living in your home

* 9. How many adults live in your home

* 10. How many adults over 65 years old live in your home

* 11. How many children live in your home under the age of 18

* 12. If one or more children under the age of 5 are in your home, have any participated in the following:

* 13. People in your home have child care that is affordable

* 14. Total 2016 household income before taxes (ranges reflect guidelines for federal assistance)

* 15. Have you experienced a serious loss of income in the last 12 months

* 16. What are your household sources of income (include all that apply)

* 17. People in your home have the ability to budget money

* 18. Your mortgage or rent payments are affordable

* 19. You have enough money to pay other monthly bills

* 20. Do you have to make hard choices to decide what to pay

* 21. What language is mostly spoken at home

* 22. People in your home are able to read and write English

* 23. Your neighborhood is safe

* 24. Is your housing safe to live in (condition of home)  Check all that apply

* 25. Your home is adequately weatherized

* 26. Your type of home is best described as follows:

* 27. Housing is as follows:

* 28. Have you moved in the last 12 months

* 29. If you have moved, how many times have you moved in the last 12 months

* 30. Have you been homeless in the last 12 months

* 31. Do all people in the home that can work have a stable job

* 32. What is your current employment status

* 33. If unemployed or seeking better employment, what could CAW/M provide that would help you most with employment   (Check all that apply)

* 34. Which best describes your typical work hours

* 35. People in your home have a regular way to get to work (reliable transportation)

* 36. Compared with people your age, how would you rate your health

* 37. People in your home have a regular doctor to see

* 38. People in your home have a regular dentist to see

* 39. People in your home have health insurance

* 40. People in your home have dental insurance

* 41. People in your home have enough food to eat

* 42. People in your home know how to get the public assistance or local services they need

* 43. What is your knowledge of Community Action Wayne/Medina

* 44. What CAW/M services have you used in the past (check all that apply)

* 45. Do you think that CAW/M provides important services

* 46. Do you find CAW/M agency hours of operation are convenient

* 47. What do you think are the major causes of poverty where you live?   (Check all that apply)

* 48. For this section, please mark any services you believe you or someone in your household would use in the next 12 months  (Check all that apply)  
Children:

* 49. For this section, please mark any services you believe you or someone in your household would use in the next 12 months:   (Check all that apply)
Finance/Assistance:

* 50. For this section, please mark any services you believe you or someone in your household would use in the next 12 months:   (Check all that apply)
Self Help:

* 51. Your comments welcome!

* 52. Please use the space below to tell us how our agency would be best able to serve you:

* 53. Thank you for helping us help you!

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