Dear Eastern Sierra Resident:

Please complete this questionnaire to help Inyo Mono Advocates for Community Action (IMACA) determine service needs in your community. Your confidential response is very important to us and provides information to identify, plan for, and fund programs that will assist you and other residents in Inyo and Mono Counties. Thank you for participating and if you have any questions or comments, please call us at (760) 873-8557 or send us an email at info@imaca.net.

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* 1. Todays Date:

Date

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* 2. What is your age?

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* 3. What is your gender?

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* 4. Please tell us your marital status:

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* 5. What language(s) do you speak at home?

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

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* 7. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

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* 8. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?

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* 9. In which community/town/area do you live or usually stay?

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* 10. In which community/town/area do you work?

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* 11. Please check if any of the following are needs for you or your family (check all that apply):

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* 12. Please tell us any additional needs you or your family have that were not listed above:

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* 13. Check how much of a problem the following barriers are to you and your family in seeking/gaining assistance with your basic needs.

  Not a Problem Somewhat of a Problem A Big Problem
Can't Afford Fees/Costs of Assistance
Not Eligible/Don't Qualify for Assistance
No Transportation to/for Assistance
Don't Know Where to go for Help
Pride (Don't want to ask for Help)
Programs/Services Not Available in my Area
No Childcare while Receiving/Obtaining Assistance
Prior Bad Experience with Service/Program
Have to Work during Service Hours
Health/Disability

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* 14. Below is a list of agencies/organizations that provide services in the Eastern Sierra. Please select any providing you and your family with assistance.

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* 15. How many people currently live in your household?

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* 16. How many children do you have? Living in Household?

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* 17. How many children, by age, currently live in your household?

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* 18. What is your approximate annual household income?

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* 19. What type(s) of income do you have? (check all that apply)

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* 20. Please tell us if you or a household member receive any of these types of assistance.

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* 21. Which of these monthly bills do you have? (Check all that apply)

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* 22. Do you or any of the members of your household have any of these financial needs or problems? (check all that apply)

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* 23. Are you a single parent?

Question Nos. 24 through 32 relate to child care services. If you do not have or need child care services, please skip to Question No. 33.

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* 24. Please mark the ages of children in your household that have or are need of child care. You may mark more than one column for each age category.

  Currently has adequate child care Currently needs child care Have tried to find child care with no success Will need child care within 6 months to one year
0  to less than 24 months
2 years to less than 3 years
3 years to less than 5 years
5 years to 12 years

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* 25. If your child/children is/are in child care, what type of child care do they receive?

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* 26. When do you need child care? (please check all that apply)

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* 27. Why do you need child care?

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* 28. If you currently receive child care, are you satisfied with the service?

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* 29. Have you ever had to go without child care when you needed it?

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* 30. Does your employer allow flexible scheduling to work around your child care needs?

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* 31. What are your barriers to obtaining child care services? (check all that apply)

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* 32. Do you need any of the following child care services? (check all that apply)

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* 33. Do you or someone in your household have any of these school/education related needs?

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* 34. How many household members do NOT currently have health insurance? (including Medicare, Medicaid, Medi-Cal, Covered California, CHIPS, Private Insurance)

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* 35. Of those household members with NO health insurance, how many are:

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* 36. If you have health insurance, who provides it?

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* 37. Do you or someone in your household have any of these healthcare needs? (check all that apply)

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* 38. What are your barriers to health care? (please check all that apply)

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* 39. Were you able to receive dental care in the last year?

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* 40. If no, why did you not receive dental care in the last year? (please check all that apply)

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* 41. What is your Employment Status? (please check one)

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* 42. If you are unemployed, please select the reason(s) why below(check all that apply):

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* 43. If UNEMPLOYED/NOT SEARCHING or UNEMPLOYED/SEARCHING, when were you last employed?

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* 44. Do you need any of the following transportation related assistance?

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* 45. What are your barriers to reliable transportation? (please check all that apply)

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* 46. What is your housing status?

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* 47. Do you have any of the following housing-related needs? (please check all that apply)

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* 48. What is your monthly housing cost? (check appropriate box)

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* 49. Please estimate your monthly utility costs: (check box with cost)

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* 50. Does your home need any of the following improvements? (please check all that apply)

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* 51. Where do you usually get your food? (please select all that apply)

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* 52. Does your household require food assistance? (please check one)

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* 53. Do you need information on how to cook food for any of these special diets? (check all that apply)

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* 54. Do you need information on food nutrition?

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* 55. Do you need to know how to store food so that it will last longer?

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* 56. Do you have reliable telephone access?

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* 57. What type of mobile telephone do you PRIMARILY use?

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* 58. Do you have access to the internet?

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* 59. Where do you usually use the internet?

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* 60. Do you or someone in your home have special needs?

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* 61. Are you a US veteran?

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* 62. If you are a US veteran, are you receiving veteran's benefits?

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* 63. If you are not receiving veteran's benefits, do you need help getting them?

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* 64. If you are a veteran or dependent, do you need assistance with any of the following? (check all that apply)

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* 65. Are you aware of the following services provided by IMACA? (please check all that apply)

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* 66. Would you like someone from IMACA to contact you about any of the following?

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* 67. Thank you for completing our survey. If you would like to enter a drawing for a $25 gift card, please provide your full name and phone number below so that we may contact you if you are chosen.

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