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

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

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

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

Your gender

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* 3. Your gender

Your marital status

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* 4. Your marital status

Highest level of education completed

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* 5. Highest level of education completed

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

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

What is your current age

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* 7. What is your current age

Total number of persons living in your home

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* 8. Total number of persons living in your home

How many adults live in your home

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* 9. How many adults live in your home

How many adults over 65 years old live in your home

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

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

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

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

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

People in your home have child care that is affordable

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

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

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

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

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

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

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

People in your home have the ability to budget money

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

Your mortgage or rent payments are affordable

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* 18. Your mortgage or rent payments are affordable

You have enough money to pay other monthly bills

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

Do you have to make hard choices to decide what to pay

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

What language is mostly spoken at home

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* 21. What language is mostly spoken at home

People in your home are able to read and write English

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

Your neighborhood is safe

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* 23. Your neighborhood is safe

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

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

Your home is adequately weatherized

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* 25. Your home is adequately weatherized

Your type of home is best described as follows:

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

Housing is as follows:

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* 27. Housing is as follows:

Have you moved in the last 12 months

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* 28. Have you moved in the last 12 months

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

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

Have you been homeless in the last 12 months

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

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

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

What is your current employment status

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* 32. What is your current employment status

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

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

Which best describes your typical work hours

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* 34. Which best describes your typical work hours

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

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

Compared with people your age, how would you rate your health

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

People in your home have a regular doctor to see

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

People in your home have a regular dentist to see

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

People in your home have health insurance

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* 39. People in your home have health insurance

People in your home have dental insurance

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* 40. People in your home have dental insurance

People in your home have enough food to eat

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

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

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

What is your knowledge of Community Action Wayne/Medina

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

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

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

Do you think that CAW/M provides important services

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

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

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

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

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

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:

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* 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:

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:

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* 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:

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:

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* 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:

Your comments welcome!

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* 51. Your comments welcome!

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

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

Thank you for helping us help you!

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* 53. Thank you for helping us help you!

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