Community Member Needs Survey 1. Demographic Information Question Title * 1. How many people live in your household? Question Title * 2. What is your sex? Male Female Question Title * 3. What is the primary language spoken in your household? English Chinese French Italian Korean Russian Spanish Vietnamese Other (please specify) Question Title * 4. What is your race? Black/African American Asian White Native Hawaiian American Indian or Alaska Native Other (please specify) Question Title * 5. What is your age? Question Title * 6. What are the ages of the other people living in your home? Number of People How many are Ages 0-3? 1 2 3 4 5 6 7 8 9 10+ How many are Ages 0-3? Number of People menu How many are Age 4? 1 2 3 4 5 6 7 8 9 10+ How many are Age 4? Number of People menu How many are Age 5? 1 2 3 4 5 6 7 8 9 10+ How many are Age 5? Number of People menu How many are Ages 6-11? 1 2 3 4 5 6 7 8 9 10+ How many are Ages 6-11? Number of People menu How many are Ages 12-17? 1 2 3 4 5 6 7 8 9 10+ How many are Ages 12-17? Number of People menu How many are Ages 18-24? 1 2 3 4 5 6 7 8 9 10+ How many are Ages 18-24? Number of People menu How many are Ages 25-55? 1 2 3 4 5 6 7 8 9 10+ How many are Ages 25-55? Number of People menu How many are Ages 56-64? 1 2 3 4 5 6 7 8 9 10+ How many are Ages 56-64? Number of People menu How many are Ages 65-74? 1 2 3 4 5 6 7 8 9 10+ How many are Ages 65-74? Number of People menu How many are Age 75 or older? 1 2 3 4 5 6 7 8 9 10+ How many are Age 75 or older? Number of People menu Next