* 1. Please select the choice that best describes you.

* 2. What county do you reside in?

* 3. Family Assessment - On a scale from 1=Not at all Serious to 5=Extremely Serious, how serious a problem do you think these factors are for families in your community?

Employment

  Not at all Serious Somewhat Serious Moderately Serious Serious Extremely Serious
Adults are unemployed and do not earn a living wage.
Youth lack employment to gain skills or income.

* 4. Family Assessment

Education and Cognitive Development

  Not at all Serious Somewhat Serious Moderately Serious Serious Extremely Serious
Adults lack a basic education.
Individuals lack a high school diploma or an equivalency certificate.
Individuals lack a recognized credential, certificate, or degree relating to the achievement of educational or vocational skills.
Individuals lack an Associate's degree.
Individuals lack a Bachelor's degree.

* 5. Family Assessment

Income and Asset Building

  Not at all Serious Somewhat Serious Moderately Serious Serious Extremely Serious
Individuals lack savings accounts.
Individuals lack savings.
Individuals lack savings to purchase an asset.
Individuals lack savings to purchase a home.
Individuals have low credit scores.
Individuals have a low net worth.

* 6. Family Assessment

Housing

  Not at all Serious Somewhat Serious Moderately Serious Serious Extremely Serious
Individuals are homeless.
Individuals lack safe and affordable housing.

* 7. Family Assessment

Health and Social Behaviors

  Not at all Serious Somewhat Serious Moderately Serious Serious Extremely Serious
Individuals lack nutrition skills (e.g. cooking, shopping, and growing food).
Individuals lack physical health and well-being.
Individuals lack mental and behavioral health and well-being.

* 8. Please check the top 3 problems facing low-income families in your community.

* 9. Community Assessment - On a scale from 1=Not at all Serious to 5=Extremely Serious, how serious a problem do you think these factors are in your community?

Employment

  Not at all serious Somewhat Serious Moderately Serious Serious Extremely Serious
There is a lack of jobs created to increase opportunities for the people with low incomes in the community.
There is a lack of "living wage" jobs created in the community.
There is a lack of jobs created in the community with a benefit package.
The unemployment rate is high in our community.
There is a lack of employment opportunity for youth in our community.

* 10. Community Assessment

Education and Cognitive Development

  Not at all Serious Somewhat Serious Moderately Serious Serious Extremely Serious
There is a lack of accessible and affordable early childhood or pre-school education assets or resources available in the community.
There is a lack of accredited or licensed affordable child care facilities available in the community.
There is a lack of accessible and affordable post secondary education assets or resources for newly graduating youth in the community. (e.g. college tuition, scholarships, vocational training, etc.)
There is a lack of accessible and affordable basic or secondary education assets or resources for adults in the community. (e.g. literacy, ESL, ABE/GED, etc.)

* 11. Community Assessment

Infrastructure and Asset Building

  Not at all Serious Somewhat Serious Moderately Serious Serious Extremely Serious
There is a lack of accessible assets/resources created in the community: Commercial Financial (Banks, Credit Unions)
Technological/Communications (e.g. broadband)
There is a lack of availability of transportation services in the community.
There is a lack of Recreational (e.g. parks, gardens, libraries)
There is a lot of abandoned or neglected buildings in the community.
There are a lot of Predatory lenders and/or lending practices in the community.

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