2019 Needs Assessment 1. Demographics Page1 / 12 8% of survey complete. Question Title * 1. Your Age: 12-17 18-23 24-44 45-54 55-69 70 & Older Question Title * 2. Your Sex: Male Female Question Title * 3. Race: White Black/African American American Indian and Alaska Native Asian Native Hawaiian and Other Pacific Islander Multi-Race (any 2 or more of the above) Other (please specify) Question Title * 4. Household Type (Choose ONE): Single Parent (Female) Single Parent (Male) Two Parent Household Single Person Two Adults/No Children Question Title * 5. Number of people in your household (Choose ONE): 1 2 3 4 5 6 More than 6 Question Title * 6. Sources of household income (Check all that apply): Wages or salary Contract work Pension or retirement benefits Social Security Workers' Compensation or other disability payments Unemployment Assistance Odd jobs TANF Farming I do not work/receive any benefits Other (please specify) Question Title * 7. Monthly household income (Choose ONE): Less than $100 $100-$250 $251-$500 $501-$750 $751-$1000 $1001-$1500 $1501-$2000 $2001+ I don't know how much my parents/guardians make Question Title * 8. Highest level of education in your household (Choose ONE): Elementary School Middle/Junior High School High School/GED Trade School Some College Associates Degree Bachelors Degree Graduate/Professional Question Title * 9. Please check the county you reside in: Baldwin Jasper Hancock Johnson Putnam Washington Wilkinson Question Title * 10. Is there a person in your household who is currently incarcerated? Yes No Question Title * 11. If YES to the above question, what is their relation to you? Mother Father Spouse Son Daughter Other parent of my child Grandparent Other (please specify) Question Title * 12. Is anyone in your household currently serving? or has served in the military? Yes (Active Military) Yes (Veteran) No Unknown Next