Introduction: Thank you for participating. This survey helps us understand community needs and improve services. Your responses are confidential and will only be reported in summary form.
Section 1: Basic Information

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1. County

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2. Zip Code

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3. Age

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4. Gender

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5. Race (Check all that apply)

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6. Household Size

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7. Children Under 18

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8. Adults over 60

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9. What is the highest level of education you've received?

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10. Total Household Yearly Income (before taxes)

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11. What types of income does your household receive? (Check all that apply)

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12. What assistance programs have you participated in? (Check all that apply)

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13. Do you identify as (Check all that apply)

Section 2: Housing Stability

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14. Current housing situation:

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15. Main source of heat

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16. In the past 12 months, have you: (check all that apply)

Section 3: Food and Nutrition

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17. Do you have access to fresh fruits and vegetables regularly?

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18. Do you or someone in your household have special dietary needs? (check all that apply)

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19. In the past 12 months, did you experience any of the following? (check all that apply)

Section 4: Financial

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20. Check the following that apply to you.

Section 5: Transportation

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21. What is your primary transportation?

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22. In the past 12 months, have you experienced the following? (check all that apply)

Section 6: Employment

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23. Employment Status

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24. In the past 12 months, have you experienced any of the following? (check all that apply)

Section 7: Childcare
(answer if applicable)

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25. In the past 12 months, have you experienced any of the following? (check all that apply)

Section 8: Physical and Mental Health

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26. Do you have health insurance?

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27. In the past 12 months, did you delay your medical care due to any of the following? (check all that apply)

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28. Have you needed mental health services but were unable to access them?

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29. In the past 12 months, have you experienced: (check all that apply)

Section 9: Seniors (65+)
(answer if applicable)

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30. Do you feel socially isolated?

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31. Do you need assistance with any of the following: (check all that apply)

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32. Do you have access to senior programs or social activities?

Section 10: Individuals with Disabilities
(answer if applicable)

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33. Do you experience difficulty accessing any of the following? (check all that apply)

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34. Do you need any of the following? (check all that apply)

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35. Are community services physically accessible?

Section 11: Community Feedback

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36. Rank your biggest worries for yourself and the people around you:

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37. What services are missing in your community?

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38. What would improve your quality of life the most right now?

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39. What prevents you from getting the services you need?

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