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* 1. Date

Date

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* 2. What county do you live in?

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* 3. Mark all services your household got from our agency within the last 12 months:

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* 4. I got the information and services I needed:

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* 5. Additional service I would like Community Action to offer:

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* 6. I had a positive experience when receiving services:

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* 7. I was informed about other agency or community services:

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* 8. Are there any problems or needs you or your family faced within the last 12 months you were unable to get help with?

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* 9. What are the greatest challenges your household is currently facing?

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* 10. What is one suggestion you have for Community Action to improve on?

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* 11. How has Community Action made a difference in your life?

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* 12. Optional: Would you be willing to share your story?

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* 13. Optional: If you're willing to share your story, please provide your contact information.

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