NWCSA Community Needs Assessment Survey

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* 1. Which county do you live in?

Ashland

Bayfield

Douglas

Iron

Price

Ashland

Bayfield

Douglas

Iron

Price

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* 2. Age (must be at least 18)

18-24

25-34

35-44

45-54

55-64

65+

18-24

25-34

35-44

45-54

55-64

65+

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* 3. Select the most appropriate choice below?

Male

Female

Other

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* 4. Which of the following best describes you?

White

African American/Black

American Indian/Alaska Native

Asian/Pacific Islander

Hispanic/Latino

Multi-racial

Other

White

African American/Black

American Indian/Alaska Native

Asian/Pacific Islander

Hispanic/Latino

Multi-racial

Other

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

8th grade or less

Some high school

High school diploma/GED

Some college

Technical or trade school

Associate Degree

Bachelor’s Degree

Graduate degree

Other

8th grade or less

Some high school

High school diploma/GED

Some college

Technical or trade school

Associate Degree

Bachelor’s Degree

Graduate degree

Other

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* 6. Do you speak a language other than English, as home as your primary language at home?

Yes

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* 7. If yes, which language?

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* 8. Which of the following best describes your working status?

Full time

Part time

Migrant Seasonal Farm Worker

Unemployed

Retired

Unable to Work

Work more than one job

Full time

Part time

Migrant Seasonal Farm Worker

Unemployed

Retired

Unable to Work

Work more than one job

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* 9. Are you currently receiving any public assistance?

Yes

Don't know

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* 10. What is the total income of adults living in your household?

Less than $10,000

$10,000-$19,999

$20,000-$29,999

$30,000-$39,999

$40,000-$49,999

$50,000-$59,999

$60,000 and above

Less than $10,000

$10,000-$19,999

$20,000-$29,999

$30,000-$39,999

$40,000-$49,999

$50,000-$59,999

$60,000 and above

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* 11. What are your sources of income? (check all that apply)

Earned wages

Veteran's benefits

Self-employment

Unemployment benefit

W2/TANF

Child support

Social security (retirement 62+)

Disability (SSI or SSDI)

Worker's Compensation

Pension/Retirement (from employer or self- funded)

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* 12. Which best describes your household?

Single parent, one or more children at home

Single

Two parent household, one or more children

Married, no children

Live with partner

Multi-generational family

Married, children not at home

Other

Single parent, one or more children at home

Single

Two parent household, one or more children

Married, no children

Live with partner

Multi-generational family

Married, children not at home

Other

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* 13. What type of job do you have?

Government

Customer Service

Non-Profit

Financial

Medical

Manufacturing

Retired

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* 14. Which of the following best describes your housing situation?

Own a house

Rent

Staying with friends/family

Mobile home (paying space/lot rent)

Homeless

Other

Own a house

Rent

Staying with friends/family

Mobile home (paying space/lot rent)

Homeless

Other

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* 15. Have you experienced homelessness?

Never

Within the last year

Within the last 5 years

At some point in your life

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* 16. Please rate the following housing concerns as they pertain to your household.

	Not a concern	Slight concern	Somewhat concern	Moderate concern	Extreme concern
Paying for rent	Paying for rent Not a concern	Paying for rent Slight concern	Paying for rent Somewhat concern	Paying for rent Moderate concern	Paying for rent Extreme concern
Dealing with landlord issues	Dealing with landlord issues Not a concern	Dealing with landlord issues Slight concern	Dealing with landlord issues Somewhat concern	Dealing with landlord issues Moderate concern	Dealing with landlord issues Extreme concern
Making house (mortgage) payments	Making house (mortgage) payments Not a concern	Making house (mortgage) payments Slight concern	Making house (mortgage) payments Somewhat concern	Making house (mortgage) payments Moderate concern	Making house (mortgage) payments Extreme concern
Paying for home repairs	Paying for home repairs Not a concern	Paying for home repairs Slight concern	Paying for home repairs Somewhat concern	Paying for home repairs Moderate concern	Paying for home repairs Extreme concern
Paying for utility bills	Paying for utility bills Not a concern	Paying for utility bills Slight concern	Paying for utility bills Somewhat concern	Paying for utility bills Moderate concern	Paying for utility bills Extreme concern
Getting insulation and/or weatherization	Getting insulation and/or weatherization Not a concern	Getting insulation and/or weatherization Slight concern	Getting insulation and/or weatherization Somewhat concern	Getting insulation and/or weatherization Moderate concern	Getting insulation and/or weatherization Extreme concern
Finding safe, affordable housing	Finding safe, affordable housing Not a concern	Finding safe, affordable housing Slight concern	Finding safe, affordable housing Somewhat concern	Finding safe, affordable housing Moderate concern	Finding safe, affordable housing Extreme concern
Paying property taxes	Paying property taxes Not a concern	Paying property taxes Slight concern	Paying property taxes Somewhat concern	Paying property taxes Moderate concern	Paying property taxes Extreme concern
Buying a house	Buying a house Not a concern	Buying a house Slight concern	Buying a house Somewhat concern	Buying a house Moderate concern	Buying a house Extreme concern
Finding emergency shelter	Finding emergency shelter Not a concern	Finding emergency shelter Slight concern	Finding emergency shelter Somewhat concern	Finding emergency shelter Moderate concern	Finding emergency shelter Extreme concern

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* 17. Please check all of the following that apply to you regarding transportation.

I carpool to work or other travel needs.

I get rides from family/friends.

I have a valid drivers license.

I have a vehicle.

I have car insurance

My vehicle is reliable.

I have bus service available

I understand the bus system

The bus service meets my needs

There are enough bus shelters

Bus shelters feel safe and comfortable

I want to be able to reach my destinations by walking & biking

Walking and biking feel safe and accessible for my travel needs

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* 18. Please mark all of the housing issues you have experienced the last 12 months.

Missed rent or mortgage payment

Evicted

Structural/Plumbing/Electrical/Heating problems

Lost home due to foreclosure or forced sale

Missed heat, electricity or other utility bill(s)

Unable to make repairs due to cost

Other

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* 19. Do you or your family receive housing assistance? (Section 8 or subsidized housing)

Yes

Don't know

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* 20. Please rate the following transportation concerns as they relate to your household

	Not a concern	Slight concern	Somewhat concern	Moderate concern	Extreme concern
Buying a reliable vehicle	Buying a reliable vehicle Not a concern	Buying a reliable vehicle Slight concern	Buying a reliable vehicle Somewhat concern	Buying a reliable vehicle Moderate concern	Buying a reliable vehicle Extreme concern
Obtaining a driver’s license	Obtaining a driver’s license Not a concern	Obtaining a driver’s license Slight concern	Obtaining a driver’s license Somewhat concern	Obtaining a driver’s license Moderate concern	Obtaining a driver’s license Extreme concern
Paying for fines/fees	Paying for fines/fees Not a concern	Paying for fines/fees Slight concern	Paying for fines/fees Somewhat concern	Paying for fines/fees Moderate concern	Paying for fines/fees Extreme concern
Paying for auto service/repairs	Paying for auto service/repairs Not a concern	Paying for auto service/repairs Slight concern	Paying for auto service/repairs Somewhat concern	Paying for auto service/repairs Moderate concern	Paying for auto service/repairs Extreme concern
Paying for auto insurance	Paying for auto insurance Not a concern	Paying for auto insurance Slight concern	Paying for auto insurance Somewhat concern	Paying for auto insurance Moderate concern	Paying for auto insurance Extreme concern
Paying for gas/diesel	Paying for gas/diesel Not a concern	Paying for gas/diesel Slight concern	Paying for gas/diesel Somewhat concern	Paying for gas/diesel Moderate concern	Paying for gas/diesel Extreme concern
Having a way to get to school or work	Having a way to get to school or work Not a concern	Having a way to get to school or work Slight concern	Having a way to get to school or work Somewhat concern	Having a way to get to school or work Moderate concern	Having a way to get to school or work Extreme concern
Finding public transportation	Finding public transportation Not a concern	Finding public transportation Slight concern	Finding public transportation Somewhat concern	Finding public transportation Moderate concern	Finding public transportation Extreme concern
Paying for bus fare	Paying for bus fare Not a concern	Paying for bus fare Slight concern	Paying for bus fare Somewhat concern	Paying for bus fare Moderate concern	Paying for bus fare Extreme concern
Using public transportation	Using public transportation Not a concern	Using public transportation Slight concern	Using public transportation Somewhat concern	Using public transportation Moderate concern	Using public transportation Extreme concern
Purchasing a reliable bicycle	Purchasing a reliable bicycle Not a concern	Purchasing a reliable bicycle Slight concern	Purchasing a reliable bicycle Somewhat concern	Purchasing a reliable bicycle Moderate concern	Purchasing a reliable bicycle Extreme concern
Paying for bike repairs or service	Paying for bike repairs or service Not a concern	Paying for bike repairs or service Slight concern	Paying for bike repairs or service Somewhat concern	Paying for bike repairs or service Moderate concern	Paying for bike repairs or service Extreme concern

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* 21. Please rate the following legal concerns as they relate to your household.

	Not a concern	Slight concern	Somewhat concern	Moderate concern	Extreme concern
Child Support Payments	Child Support Payments Not a concern	Child Support Payments Slight concern	Child Support Payments Somewhat concern	Child Support Payments Moderate concern	Child Support Payments Extreme concern
Bank Foreclosure on home	Bank Foreclosure on home Not a concern	Bank Foreclosure on home Slight concern	Bank Foreclosure on home Somewhat concern	Bank Foreclosure on home Moderate concern	Bank Foreclosure on home Extreme concern
Bankruptcy	Bankruptcy Not a concern	Bankruptcy Slight concern	Bankruptcy Somewhat concern	Bankruptcy Moderate concern	Bankruptcy Extreme concern
Domestic Abuse	Domestic Abuse Not a concern	Domestic Abuse Slight concern	Domestic Abuse Somewhat concern	Domestic Abuse Moderate concern	Domestic Abuse Extreme concern
Creditors/Debt Collectors	Creditors/Debt Collectors Not a concern	Creditors/Debt Collectors Slight concern	Creditors/Debt Collectors Somewhat concern	Creditors/Debt Collectors Moderate concern	Creditors/Debt Collectors Extreme concern
Eviction	Eviction Not a concern	Eviction Slight concern	Eviction Somewhat concern	Eviction Moderate concern	Eviction Extreme concern
Public Benefits Programs	Public Benefits Programs Not a concern	Public Benefits Programs Slight concern	Public Benefits Programs Somewhat concern	Public Benefits Programs Moderate concern	Public Benefits Programs Extreme concern
Government Health Insurance	Government Health Insurance Not a concern	Government Health Insurance Slight concern	Government Health Insurance Somewhat concern	Government Health Insurance Moderate concern	Government Health Insurance Extreme concern
Veteran’s Benefits	Veteran’s Benefits Not a concern	Veteran’s Benefits Slight concern	Veteran’s Benefits Somewhat concern	Veteran’s Benefits Moderate concern	Veteran’s Benefits Extreme concern

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* 22. Do you currently have health insurance?

Yes

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* 23. Please check all of the insurance coverage in your household.

No health insurance

Health insurance through an employer

Health insurance purchased directly by yourself or family (not employer)

Indian or Tribal Health

Medicare

Medicaid/Medical Assistance (MA)

Veterans benefits (ex. CHAMPUS/Tricare)

BadgerCare

Other

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* 24. Which of the following stops you from seeing a doctor when you have a health need? (check all that apply)

Nothing stops me from seeing a doctor

Lack/cost of transportation

Cost of medical care

Problem was minor so I treated myself

No appointment would fit in my schedule

Lack of doctors, therapists or counselors

Language barrier

Lack of specialists

Fear or lack of trust

No health insurance

No child care

Other

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* 25. Which of the following stops you from seeing a dentist when you have a dental need? (check all that apply)

Nothing stops me from seeing a dentist

Lack/cost of transportation

Cost of dental care

Language barrier

No appointment would fit in my schedule

Lack of specialists

Lack of doctors, therapists or counselors

Fear or lack of trust

No dental insurance

No child care

Other

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* 26. Which of the following stops you from seeing help when you have a mental health need? (check all that apply)

Nothing stops me from seeing a mental health professional

Lack/cost of transportation

Cost of mental health visit

No appointment would fit in my schedule

Language barrier

Fear/lack of trust

Lack of therapists or counselors

No mental health insurance

No child care

Other

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* 27. .

	No concern	Slight concern	Somewhat concern	Moderate concern	Extreme concern
How concerned are you about your mental health?	How concerned are you about your mental health? No concern	How concerned are you about your mental health? Slight concern	How concerned are you about your mental health? Somewhat concern	How concerned are you about your mental health? Moderate concern	How concerned are you about your mental health? Extreme concern
How concerned are you about your family or friends' mental health?	How concerned are you about your family or friends' mental health? No concern	How concerned are you about your family or friends' mental health? Slight concern	How concerned are you about your family or friends' mental health? Somewhat concern	How concerned are you about your family or friends' mental health? Moderate concern	How concerned are you about your family or friends' mental health? Extreme concern

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* 28. I feel confident that I can afford my prescription medication(s).

Yes

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* 29. I feel confident I have access to treatment facilities & professionals for substance abuse/ addiction issues.

Yes

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* 30. I am a grandparent responsible for child care

Yes

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* 31. Do you or a member of your household use any of the following substances (remember, your responses are anonymous!) Check all that apply.

Tobacco or other nicotine related products

Marijuana

Alcohol

Illegal drugs

Prescription drugs that are not prescribed to you

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* 32. Please rate the following child care concerns as they pertain to your household.

	Not a concern	Slight concern	Somewhat concern	Moderate concern	Extreme concern
Finding safe, affordable child care	Finding safe, affordable child care Not a concern	Finding safe, affordable child care Slight concern	Finding safe, affordable child care Somewhat concern	Finding safe, affordable child care Moderate concern	Finding safe, affordable child care Extreme concern
Finding a child care facility	Finding a child care facility Not a concern	Finding a child care facility Slight concern	Finding a child care facility Somewhat concern	Finding a child care facility Moderate concern	Finding a child care facility Extreme concern
Keeping multi-age children together in one location	Keeping multi-age children together in one location Not a concern	Keeping multi-age children together in one location Slight concern	Keeping multi-age children together in one location Somewhat concern	Keeping multi-age children together in one location Moderate concern	Keeping multi-age children together in one location Extreme concern
Transportation to child care	Transportation to child care Not a concern	Transportation to child care Slight concern	Transportation to child care Somewhat concern	Transportation to child care Moderate concern	Transportation to child care Extreme concern
Cost of child care	Cost of child care Not a concern	Cost of child care Slight concern	Cost of child care Somewhat concern	Cost of child care Moderate concern	Cost of child care Extreme concern
Available hours don’t match work schedule	Available hours don’t match work schedule Not a concern	Available hours don’t match work schedule Slight concern	Available hours don’t match work schedule Somewhat concern	Available hours don’t match work schedule Moderate concern	Available hours don’t match work schedule Extreme concern

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* 33. Please rate the following food security concerns as they pertain to your household.

	Yes	No	Maybe
In the past year, was there ever a time when you could not afford to provide your household with enough food?	In the past year, was there ever a time when you could not afford to provide your household with enough food? Yes	In the past year, was there ever a time when you could not afford to provide your household with enough food? No	In the past year, was there ever a time when you could not afford to provide your household with enough food? Maybe
In the past year, I/we have been able to afford to buy fresh fruits and vegetables every week.	In the past year, I/we have been able to afford to buy fresh fruits and vegetables every week. Yes	In the past year, I/we have been able to afford to buy fresh fruits and vegetables every week. No	In the past year, I/we have been able to afford to buy fresh fruits and vegetables every week. Maybe
In the past year, I/we have purchased food from a farmer’s market.	In the past year, I/we have purchased food from a farmer’s market. Yes	In the past year, I/we have purchased food from a farmer’s market. No	In the past year, I/we have purchased food from a farmer’s market. Maybe
In the last 5 years, I/we have used the FoodShare (Food Stamps) program.	In the last 5 years, I/we have used the FoodShare (Food Stamps) program. Yes	In the last 5 years, I/we have used the FoodShare (Food Stamps) program. No	In the last 5 years, I/we have used the FoodShare (Food Stamps) program. Maybe
In the last 5 years, I/we were enrolled in WIC.	In the last 5 years, I/we were enrolled in WIC. Yes	In the last 5 years, I/we were enrolled in WIC. No	In the last 5 years, I/we were enrolled in WIC. Maybe
In the past year, I/we have used a community food program (food distribution/pantries/free meals/etc.)	In the past year, I/we have used a community food program (food distribution/pantries/free meals/etc.) Yes	In the past year, I/we have used a community food program (food distribution/pantries/free meals/etc.) No	In the past year, I/we have used a community food program (food distribution/pantries/free meals/etc.) Maybe
I/we would like to learn how to prepare healthy meals.	I/we would like to learn how to prepare healthy meals. Yes	I/we would like to learn how to prepare healthy meals. No	I/we would like to learn how to prepare healthy meals. Maybe
I/we garden to grow our own food.	I/we garden to grow our own food. Yes	I/we garden to grow our own food. No	I/we garden to grow our own food. Maybe
I/we would be interested in learning how to garden to grow food.	I/we would be interested in learning how to garden to grow food. Yes	I/we would be interested in learning how to garden to grow food. No	I/we would be interested in learning how to garden to grow food. Maybe

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* 34. Please rate the following employment concerns as they pertain to your household.

	Not a concern	Slight concern	Somewhat concern	Moderate concern	Extreme concern
Finding a job	Finding a job Not a concern	Finding a job Slight concern	Finding a job Somewhat concern	Finding a job Moderate concern	Finding a job Extreme concern
Finding a full time job	Finding a full time job Not a concern	Finding a full time job Slight concern	Finding a full time job Somewhat concern	Finding a full time job Moderate concern	Finding a full time job Extreme concern
Finding a job with higher wages	Finding a job with higher wages Not a concern	Finding a job with higher wages Slight concern	Finding a job with higher wages Somewhat concern	Finding a job with higher wages Moderate concern	Finding a job with higher wages Extreme concern
Finding Housing	Finding Housing Not a concern	Finding Housing Slight concern	Finding Housing Somewhat concern	Finding Housing Moderate concern	Finding Housing Extreme concern
Getting training for a better job	Getting training for a better job Not a concern	Getting training for a better job Slight concern	Getting training for a better job Somewhat concern	Getting training for a better job Moderate concern	Getting training for a better job Extreme concern
Getting a job with health benefits	Getting a job with health benefits Not a concern	Getting a job with health benefits Slight concern	Getting a job with health benefits Somewhat concern	Getting a job with health benefits Moderate concern	Getting a job with health benefits Extreme concern
Securing childcare	Securing childcare Not a concern	Securing childcare Slight concern	Securing childcare Somewhat concern	Securing childcare Moderate concern	Securing childcare Extreme concern
Transportation to interview/work site	Transportation to interview/work site Not a concern	Transportation to interview/work site Slight concern	Transportation to interview/work site Somewhat concern	Transportation to interview/work site Moderate concern	Transportation to interview/work site Extreme concern

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* 35. What are the biggest health concerns in your family?

Physical Activity/Nutrition

Overweight & Obesity

Tobacco

Substance Abuse

HIV/AIDS

Mental Health

Injury/Violence

Environmental Quality

Other (please specify)

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* 36. Please answer the following statements about you and /or your household relating to money and education.

	Yes	No	Don't know
I have an account at a bank or credit union (e.g. checking, saving, CD, IRA, etc.)	I have an account at a bank or credit union (e.g. checking, saving, CD, IRA, etc.) Yes	I have an account at a bank or credit union (e.g. checking, saving, CD, IRA, etc.) No	I have an account at a bank or credit union (e.g. checking, saving, CD, IRA, etc.) Don't know
My family and I receive the Earned Income Tax Credit.	My family and I receive the Earned Income Tax Credit. Yes	My family and I receive the Earned Income Tax Credit. No	My family and I receive the Earned Income Tax Credit. Don't know
I have money in savings available to me.	I have money in savings available to me. Yes	I have money in savings available to me. No	I have money in savings available to me. Don't know
I need help completing my own tax forms.	I need help completing my own tax forms. Yes	I need help completing my own tax forms. No	I need help completing my own tax forms. Don't know
I need help learning how to budget my monthly expenses.	I need help learning how to budget my monthly expenses. Yes	I need help learning how to budget my monthly expenses. No	I need help learning how to budget my monthly expenses. Don't know
I need help balancing my checkbook.	I need help balancing my checkbook. Yes	I need help balancing my checkbook. No	I need help balancing my checkbook. Don't know
I need help understanding my credit report.	I need help understanding my credit report. Yes	I need help understanding my credit report. No	I need help understanding my credit report. Don't know
I/someone in my household needs additional education to earn a living wage. (support your household without government benefits.)	I/someone in my household needs additional education to earn a living wage. (support your household without government benefits.) Yes	I/someone in my household needs additional education to earn a living wage. (support your household without government benefits.) No	I/someone in my household needs additional education to earn a living wage. (support your household without government benefits.) Don't know
I/someone in my household needs assistance with basic literacy. (reading, writing, and/or math)	I/someone in my household needs assistance with basic literacy. (reading, writing, and/or math) Yes	I/someone in my household needs assistance with basic literacy. (reading, writing, and/or math) No	I/someone in my household needs assistance with basic literacy. (reading, writing, and/or math) Don't know
I/someone in my household needs assistance learning basic computer literacy skills.	I/someone in my household needs assistance learning basic computer literacy skills. Yes	I/someone in my household needs assistance learning basic computer literacy skills. No	I/someone in my household needs assistance learning basic computer literacy skills. Don't know
I/someone in my household needs assistance learning to speak English.	I/someone in my household needs assistance learning to speak English. Yes	I/someone in my household needs assistance learning to speak English. No	I/someone in my household needs assistance learning to speak English. Don't know

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* 37. What services are needed most for the children?

Child Care

Doctor/Dentist

Foster Care/Family Placement

Parenting Classes

In Home Care

Before/After School/Summer Activities

Housing

N/A

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* 38. Of the 8 areas discussed, please identify the TOP 3 that have the largest impact on your household.

	Extreme concern (1)	Moderate concern (2)	Slight concern (3)	Least concern (4)	Least concern (5)	Least concern (6)	Least concern (7)	Least concern (8)
Food/Nutrition	Food/Nutrition Extreme concern (1)	Food/Nutrition Moderate concern (2)	Food/Nutrition Slight concern (3)	Food/Nutrition Least concern (4)	Food/Nutrition Least concern (5)	Food/Nutrition Least concern (6)	Food/Nutrition Least concern (7)	Food/Nutrition Least concern (8)
Physical Health	Physical Health Extreme concern (1)	Physical Health Moderate concern (2)	Physical Health Slight concern (3)	Physical Health Least concern (4)	Physical Health Least concern (5)	Physical Health Least concern (6)	Physical Health Least concern (7)	Physical Health Least concern (8)
Mental Health	Mental Health Extreme concern (1)	Mental Health Moderate concern (2)	Mental Health Slight concern (3)	Mental Health Least concern (4)	Mental Health Least concern (5)	Mental Health Least concern (6)	Mental Health Least concern (7)	Mental Health Least concern (8)
Employment/Income	Employment/Income Extreme concern (1)	Employment/Income Moderate concern (2)	Employment/Income Slight concern (3)	Employment/Income Least concern (4)	Employment/Income Least concern (5)	Employment/Income Least concern (6)	Employment/Income Least concern (7)	Employment/Income Least concern (8)
Transportation	Transportation Extreme concern (1)	Transportation Moderate concern (2)	Transportation Slight concern (3)	Transportation Least concern (4)	Transportation Least concern (5)	Transportation Least concern (6)	Transportation Least concern (7)	Transportation Least concern (8)
Housing	Housing Extreme concern (1)	Housing Moderate concern (2)	Housing Slight concern (3)	Housing Least concern (4)	Housing Least concern (5)	Housing Least concern (6)	Housing Least concern (7)	Housing Least concern (8)
Child care	Child care Extreme concern (1)	Child care Moderate concern (2)	Child care Slight concern (3)	Child care Least concern (4)	Child care Least concern (5)	Child care Least concern (6)	Child care Least concern (7)	Child care Least concern (8)
Legal Issues	Legal Issues Extreme concern (1)	Legal Issues Moderate concern (2)	Legal Issues Slight concern (3)	Legal Issues Least concern (4)	Legal Issues Least concern (5)	Legal Issues Least concern (6)	Legal Issues Least concern (7)	Legal Issues Least concern (8)

NWCSA Community Needs Assessment Survey

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* 1. Which county do you live in?

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* 2. Age (must be at least 18)

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* 3. Select the most appropriate choice below?

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* 4. Which of the following best describes you?

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

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* 6. Do you speak a language other than English, as home as your primary language at home?

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* 7. If yes, which language?

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* 8. Which of the following best describes your working status?

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* 9. Are you currently receiving any public assistance?

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* 10. What is the total income of adults living in your household?

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* 11. What are your sources of income? (check all that apply)

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* 12. Which best describes your household?

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* 13. What type of job do you have?

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* 14. Which of the following best describes your housing situation?

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* 15. Have you experienced homelessness?

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* 16. Please rate the following housing concerns as they pertain to your household.

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* 17. Please check all of the following that apply to you regarding transportation.

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* 18. Please mark all of the housing issues you have experienced the last 12 months.

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* 19. Do you or your family receive housing assistance? (Section 8 or subsidized housing)

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* 20. Please rate the following transportation concerns as they relate to your household

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* 21. Please rate the following legal concerns as they relate to your household.

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* 22. Do you currently have health insurance?

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* 23. Please check all of the insurance coverage in your household.

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* 24. Which of the following stops you from seeing a doctor when you have a health need? (check all that apply)

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* 25. Which of the following stops you from seeing a dentist when you have a dental need? (check all that apply)

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* 26. Which of the following stops you from seeing help when you have a mental health need? (check all that apply)

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* 27. .

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* 28. I feel confident that I can afford my prescription medication(s).

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* 29. I feel confident I have access to treatment facilities & professionals for substance abuse/ addiction issues.

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* 30. I am a grandparent responsible for child care

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* 31. Do you or a member of your household use any of the following substances (remember, your responses are anonymous!) Check all that apply.

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* 32. Please rate the following child care concerns as they pertain to your household.

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* 33. Please rate the following food security concerns as they pertain to your household.

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* 34. Please rate the following employment concerns as they pertain to your household.

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* 35. What are the biggest health concerns in your family?

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* 36. Please answer the following statements about you and /or your household relating to money and education.

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* 37. What services are needed most for the children?

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* 38. Of the 8 areas discussed, please identify the TOP 3 that have the largest impact on your household.

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* 39. What have we not asked you about you/your household/your community needs that you feel are important?