Part A

Dear Parents and/or Guardian: Thank you for taking time to respond to our survey. Your answers are confidential and will be added to other answers in order to design a more relevant and comprehensive plan that assist families with young children enrolled in our Head Start program.

Regards, Head Start Center Director
How serious of a problem do you feel each of the following items is in your City/Town? (Please check your response.) Scale:(1) Not a Problem (2) Somewhat (3) Problem (4) Serious Problem (5) Very Serious Problem

Question Title

* 1. How serious of a problem do you feel each of the following items is in your City/Town? (Please check your response.) Scale:(1) Not a Problem (2) Somewhat (3) Problem (4) Serious Problem (5) Very Serious Problem

  1 2 3 4 5
Access to health care
Availability of affordable housing
Affordable child care before and after school hours
Availability of recreation for families (parks, church programs, membership organizations)
Quality of public education in your city or town
Availability of adult education (GED, ESL, etc.)
Availability of job training
Utility costs (heating, electricity, water)
Services for children with disabilities
Low wages
Availability of jobs
Public safety/crime
Availability and access to public transportation
Incidence of drug and alcohol abuse
Gang activity
Child health issues (obesity, exposure to lead, asthma)
Incarceration of parents
Access to public assistance (WIC, Food Stamps - SNAP, TANF)
Domestic Violence
Child abuse and neglect
Addiction to opioids
Please select the top THREE reasons you feel are the primary causes of poverty in your City/Town.

Question Title

* 2. Please select the top THREE reasons you feel are the primary causes of poverty in your City/Town.

Has there been a time in the last year when you or someone in your immediate family:(Check YES or NO)

Question Title

* 3. Has there been a time in the last year when you or someone in your immediate family:(Check YES or NO)

  Yes No
Needed to see a dentist but couldn't afford to?
Needed to see a doctor but couldn't afford to?
Needed to buy medicine but couldn't afford to?
Needed food but couldn't afford to buy it?
Went hungry?
Could not pay the rent?
Had utilities turned off? (Couldn't pay)
Had utilities turned off? (Landlord failed to pay)
Could not pay mortgage or taxes?
Been evicted?
Had home condemned?
Looked for work but could not get a job?
Lost a job?
Needed assistance but did not receive it?

T