1. DEMOGRAPHIC INFORMATION

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* 1. How many people live in your household?

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* 2. What is your gender?

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* 3. What is the primary language spoken in your household?

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* 4. Are you of Hispanic, Latino or Spanish origin?

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* 5. What is your race?
Check all that apply

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* 6. What is your age?

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* 7. What are the ages of the other people living in your home? (Indicate how many)

  1 2 3 4 5 6 7 8 9
Age 0-3
Age 4
Age 5
Age 6-11
Age 12-17
Age 18-24
Age 25-55
Age 56-64
Age 65-74
Age 75+

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* 8. What city do you live in?

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* 9. What is the highest level of education you have completed?

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* 10. Which best describes your marital status?

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* 11. What have been your household’s top THREE needs within the past 12 months?
Check three that apply:

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* 12. Check ALL of the services that you or someone in your household needed but did NOT receive within the past 12 months.
Check all that apply

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* 13. If you needed services and did not get them, what was the reason?

 
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