What is your sex?

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* 2. What is your sex?

What language do you speak at home?

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* 3. What language do you speak at home?

What is your race?

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* 4. What is your race?

What is your age?

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* 5. What is your age?

Enter the number, in each age group, living in the household.

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* 6. Enter the number, in each age group, living in the household.

In what ZIP code is your home located? (enter 5-digit ZIP code)

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* 7. In what ZIP code is your home located? (enter 5-digit ZIP code)

What is the highest level of school you have completed or the highest degree you have received?

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* 8. What is the highest level of school you have completed or the highest degree you have received?

Have any of the following been a need in your home in the past 12 months? (Please check all that apply)

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* 9. Have any of the following been a need in your home in the past 12 months? (Please check all that apply)

If you were unable to get the help you needed, why?

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* 10. If you were unable to get the help you needed, why?

If substance abuse has affected your household, were heroin/opioids (including meth) a factor?

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* 11. If substance abuse has affected your household, were heroin/opioids (including meth) a factor?

Have you received any services from Adirondack Community
Action Programs, Inc. (ACAP) in the past 12 months?

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* 12. Have you received any services from Adirondack Community
Action Programs, Inc. (ACAP) in the past 12 months?

Are you familiar with ACAP?

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* 13. Are you familiar with ACAP?

If yes, how did you hear about ACAP? (Check all that apply)

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* 14. If yes, how did you hear about ACAP? (Check all that apply)

Which of the following do you or other members in your household use? Check all that apply

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* 15. Which of the following do you or other members in your household use? Check all that apply

In the past 12 months, has a lack of transportation been a problem for your household?

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* 16. In the past 12 months, has a lack of transportation been a problem for your household?

If yes, were any of the following the issue?

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* 17. If yes, were any of the following the issue?

Enter the number of people in your household in each group.

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* 18. Enter the number of people in your household in each group.

If adults (18 and over) are not working, please indicate why?  Check all that apply.

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* 19. If adults (18 and over) are not working, please indicate why?  Check all that apply.

What income or benefits help support your household? (Yours or anyone else living in the household)

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* 20. What income or benefits help support your household? (Yours or anyone else living in the household)

What is your approximate average household income?

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* 21. What is your approximate average household income?

Do you or anyone in your household need help with any of the following?

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* 22. Do you or anyone in your household need help with any of the following?

In the past 12 months, have you or anyone in your household experienced any of the following? Check all that apply

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* 23. In the past 12 months, have you or anyone in your household experienced any of the following? Check all that apply

What is your housing situation?

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* 24. What is your housing situation?

I live in:

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* 25. I live in:

Which best describes the condition of your home? Check all that apply

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* 26. Which best describes the condition of your home? Check all that apply

Are you at risk of becoming homeless?

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* 27. Are you at risk of becoming homeless?

Have any of the following affected your housing situation in the past 12 months?

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* 28. Have any of the following affected your housing situation in the past 12 months?

In the past 12 months, have you or anyone in your household skipped or cut the size of a meal because there was not enough food?

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* 29. In the past 12 months, have you or anyone in your household skipped or cut the size of a meal because there was not enough food?

If yes, how often have you or anyone in your household skipped or cut the size of a meal?

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* 30. If yes, how often have you or anyone in your household skipped or cut the size of a meal?

In the past 12 months, have you or anyone in your household used any of the following? Check all that apply

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* 31. In the past 12 months, have you or anyone in your household used any of the following? Check all that apply

In the past 12 months, have you or anyone in your household had to choose between buying food or paying a bill? (rent/mortgage, heat, etc.)

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* 32. In the past 12 months, have you or anyone in your household had to choose between buying food or paying a bill? (rent/mortgage, heat, etc.)

Do your dependent children currently have health insurance?

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* 33. Do your dependent children currently have health insurance?

Do all the adults in your household (21 and over) have health insurance?

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* 34. Do all the adults in your household (21 and over) have health insurance?

Do you feel safe in your neighborhood?

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* 35. Do you feel safe in your neighborhood?

Is there anyone in your household with a disability?

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* 36. Is there anyone in your household with a disability?

If yes, which

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* 37. If yes, which

Do you have children, 13 and younger in your household? (If no, skip to question 45)

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* 38. Do you have children, 13 and younger in your household? (If no, skip to question 45)

What do you currently use to meet your childcare needs? Check all that apply

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* 39. What do you currently use to meet your childcare needs? Check all that apply

What time of day do you need childcare? Check all that apply

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* 40. What time of day do you need childcare? Check all that apply

Have you ever used a day care center or registerd childcare provider?

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* 41. Have you ever used a day care center or registerd childcare provider?

If no, why?

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* 42. If no, why?

How do you meet the cost or your childcare?

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* 43. How do you meet the cost or your childcare?

Have any of the following been an issue for the youth (under 18) in your household? Check all that apply

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* 44. Have any of the following been an issue for the youth (under 18) in your household? Check all that apply

Is your child up to date on immunizations?

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* 45. Is your child up to date on immunizations?

Are you a grandparent or other relative raising children other than your own?

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* 46. Are you a grandparent or other relative raising children other than your own?

What service(s) are needed to meet your families needs?

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* 47. What service(s) are needed to meet your families needs?

What is one service that has helped you or someone in household in the past 12 months?  Please name the service and why you feel it was helpful.

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* 48. What is one service that has helped you or someone in household in the past 12 months?  Please name the service and why you feel it was helpful.

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