Community Resource Survey

Question Title

* 1. Which describes you:

Community Based Organization

Faith Based Organization

Private Sector

Public Sector

Educational Institution

Elected Official

Low Income

Media

Mental Health Agency

Substance Abuse Agency

Program Participant/Client of Community Action

Employee of Community Action

Donor of Community Action

Volunteer of Community Action

Board Member of Community Action

Caregiver for the Elderly

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* 2. What is your gender?

Female Male

Other (specify) __________________________________________

Question Title

* 3. What is your race?

White or Caucasian

American Indian or Alaska Native

Black or African American

Native Hawaiian or Other Pacific Islander

Asian or Asian American

Other (please specify) ______________________________________________________

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* 4. What is your ethnicity?

Hispanic

Non Hispanic

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* 5. What is your Age Group

Under 18

18-24

25-38

39-50

62+

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* 6. What is the highest level of school you have completed or the highest degree you have received?

Less than a high school degree

High school degree or equivalent (e.g. GED)

Some college but no degree

Associate Degree

Bachelor Degree

Graduate Degree

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* 7. Which of the following categories best describes your employment status?

Employed Full Time, working 32 hours or more per week

Employed Part Time, working 1-31 hours per week

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

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* 8. Housing Status:

Own

Hotel/Motel

Rent Nursing/Long Term Care

Staying with Family or Friends Assisted Living

Homeless-streets/car Group Home

Homeless-shelter Halfway House

Other (please specify) _________________________________________

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* 9. What is Your Family Situation?

Single Parent

Two Parent

Raising Someone Else's Children, Not Family

Foster Parents

Raising Own Children and Children of Others

Children Raised by Another Family Member (Grandparents, etc.)

Shared Custody

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* 10. Have you used any Clinton County Community Action Programs in the past 12 months?

Yes