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* 1. What city or town do you live in?

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* 2. How many of the following are in your household?

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* 3. Please indicate your gender identity. 

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* 4. What is your age group?

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* 5. Housing (Please select one)

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* 6. Please select the option that best describes your race.

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* 7. Are you Hispanic?

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* 8. How much income does your household have in a year?

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* 9. In your house, what language is spoken most?

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* 10. Are you or a member of your household currently a member of the US Armed Forces or a Military Veteran?

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* 11. Please select the highest level of education completed in your household.

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* 12. Prior to COVID-19, did your household need assistance of any kind this past year?

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* 13. Due to COVID-19, have you or your household experienced any of the following? Please mark all that apply.

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* 14. Based on the current needs of your household and your community, please rate each of the issues below.

  A Critical Concern Somewhat a Concern Not at All a Concern
Food Costs
Access to Healthy Foods
Housing Rent Costs
Homelessness
Utility Costs
Credit Card or Loan Debt
Parenting Support and Education
Children's Education/Tutoring
High School Drop-outs
Affordable Day Care
Neighborhood Safety and Security
Paying for College
Health Insurance/Health Costs
Programs for Youth/Teens
Juvenile Delinquency/Crime
Drug or Alcohol Abuse
Domestic Violence
Programs for Seniors
Services for the Disabled
Veterans' Services
Mental Health Services
Language Barriers
Immigration/Citizenship Issues
Incarceration/Re-entry issues
Finding a Job
Job Trainig

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* 15. Which ONE item of the list above is the MOST important need right now?

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* 16. Please share any comments about how COVID 19 has impacted you or your household?

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