* 2. What is your sex?

* 3. What language do you speak at home?

* 4. What is your race?

* 5. What is your age?

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

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

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

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

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

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

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

* 13. Are you familiar with ACAP?

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

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

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

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

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

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

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

* 21. What is your approximate average household income?

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

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

* 24. What is your housing situation?

* 25. I live in:

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

* 27. Are you at risk of becoming homeless?

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

* 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?

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

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

* 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.)

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

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

* 35. Do you feel safe in your neighborhood?

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

* 37. If yes, which

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

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

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

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

* 42. If no, why?

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

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

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

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

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

* 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.

T