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* 1. What is the county you live in?

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* 2. What is your age (must be 18 or older)?

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* 3. What is your gender?

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* 4. Select the highest level of education you have completed?

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* 5. What is your ethnicity?

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

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* 7. What category best describes your household? Please choose only one.

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* 8. Please check all the following that apply to you, regarding transportation.

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

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

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* 11. How many total people live in your household?

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* 12. How many children aged 5 and under live in your household?

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* 13. What are your household's income sources? Check all that apply.

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* 14. Which employment status best describes you? Check all that apply.

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* 15. Have you experienced any of the following housing problems in the last 12 months? Check all that apply.

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* 16. Please identify the top three areas of challenge which have had the biggest impact on you/your household over the past year. Please check 3 options.

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* 17. If/when you experienced any of those challenges, did you seek assistance from any of the following?

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* 18. Were you able to receive the assistance you needed?

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* 19. If you received services from ADVOCAP, which services did you receive? Check all that apply.

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* 20. Please rate the availability and quality of the following services in your community.

  Not Available Available but poor quality Available and acceptable Unknown
Child care
Employment Opportunities
Public education
Recreational facilities/events
Career focused education

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* 21. What services could your community provide to help people improve their lives?

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* 22. Please rate the following HOUSING concerns as they relate to your household.

  Not a Concern Somewhat a Concern Extreme Concern
Paying rent
Dealing with landlord issue
Making house (mortgage) payment
Paying for home repairs
Paying for utility bills
Getting insulation and/or weatherization
Finding safe, affordable housing
Paying property taxes
Buying a house
Finding emergency shelter
Finding housing large enough for my family

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* 23. Please rate the following TRANSPORTATION concerns as they relate to your household.

  Not a Concern Somewhat a Concern Extreme Concern
Buying a reliable vehicle
Obtaining a driver's license
Paying for fines
Paying for auto/service repairs
Paying for auto insurance
Paying for gas/diesel
Having a way to get to school or work
Finding public transportation

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* 24. Please rate the following LEGAL concerns as they relate to your household.

  Not a Concern Somewhat a Concern Extreme Concern
Child support payments
Bank foreclosure on home
Bankruptcy
Domestic violence/abuse
Delinquent property tax
Creditors/debt collection
Eviction
Denial of public benefits
Drug or alcohol related charges
Divorce/custody
Traffic/automobile charges

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* 25. What types of insurance do you or someone in your household have? Check all that apply.

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* 26. Which of the following stops you from seeing a DOCTOR when you need to? Check all that apply.

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* 27. Which of the following stops you from seeing a DENTIST when you need to? Check all that apply.

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* 28. Which of the following stops you from seeking help when you have a MENTAL HEALTH need? Check all that apply.

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* 29. Which of the following stops you from seeking help when you have an ALCOHOL or DRUG ADDITION (AODA) need? Check all that apply.

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* 30. How concerned are you about your family or friends' mental health (may include stress, anxiety, or depression)?

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* 31. Please answer the following health care statements as they relate to you/your household in the past year.

  Yes No
I (or someone in my household) haven't filled medical prescriptions because I couldn't afford it.
I (or someone in my household) have not bought medically necessary items (glasses, hearing aids, ect) because I couldn't afford it.
I (or someone in my household) have gone to a free clinic to see a doctor.

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* 32. Please answer the following statements about you and/or your household.

  Yes No Unsure
I have an account at a bank or credit union (e.g. checking, savings, CD, IRA).
My family and I receive the Earned Income Tax Credit.
I have money in savings.
I need help learning how to budget my monthly expenses.
I need help completing my own tax forms.
I need help balancing my checkbook.
I need help understanding my credit report.
I (or someone in my household) need additional education to earn a living wage (support household without government benefits).
I (or someone in my household) need assistance with basic literacy (reading, writing, and/or math).
I (or someone in my household) need assistance learning basic computer skills.
I (or someone in my household) need assistance learning to speak English.

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* 33. Do you have any of the following in your household? Check all that apply.

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* 34. Please indicate either "yes" or "no" to each statement as it applies to your household.

  Yes No
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, I/we have been able to afford to buy fresh fruits and vegetables every week.
In the past year, I/we have purchased food at the Farmer's Market.
In the past year, I/we have used a community food program (food distributions/pantries, free meals, etc).
In the last 5 years, I/we have used the FoodShare (food stamps) program.
I/we would like to learn how to prepare healthy meals.
I/we would like to grow our own food.
I/we can or preserve food.
I/we would be interested in learning how to can or preserve food.

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* 35. What have we not asked you about you, your household, or your community that feels important to you?

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* 36. Since this survey is confidential, your information is not listed. If you would like someone from ADVOCAP to contact you regarding services, please leave your name, phone number, and/or email address and someone from the ADVOCAP office in your community will contact you.

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