1. Dolly Parton's Imagination Library in Onondaga County Survey

Thank you for your participation in Dolly Parton's Imagination Library Program. This intake survey will help the Literacy Coalition of Onondaga County (that runs this program) and its partners plan, evaluate and coordinate their work. No identifying information for you or your child will be shared. You are not required to complete this survey to participate in the Imagination Library program. If you decline to answer this survey, scroll to the bottom and click next until it brings you to the end of the survey and then click done.
Thank you so very much!

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1. What is your email address (note an email address is required for online registration)?

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2. What is your address? (example: 300 Summit St, Syracuse, NY 13202) - Do not add apartment numbers and be sure to add in City, State and Zip Code.

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3. What is the first name of the child you are registering?

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4. What is the last name of the child you are registering?

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5. What is the date of birth for the child you are registering?

Date

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6. What is today's date?

Date

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7. How many times have you or someone in your house read to your child in the past 7 days?

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8. When you or someone in your house reads to your child, how often do you: Stop reading and ask your child to tell you what is in the picture?

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9. When you or someone in your house reads to your child, how often do you: Stop reading and ask what a letter is?

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10. When you or someone in your house reads to your child, how often do you: Ask your child to read with you?

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11. When you or someone in your house reads to your child, how often do you: Talk about the story and ask your child questions about the story?

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12. In the past seven days, how many times has your child asked that you read to him or her?

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13. In the past seven days, how often has your child spent time looking at books by himself?

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14. Our total household income last year was:

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15. What is your race?

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16. What country were you born in?

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17. Do you have long-term housing that you can afford?

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18. Do you feel safe in your neighborhood?

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19. Do you have enough food?

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20. Do you pay for your own housing and food without government support?

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21. Do you have dependable and safe transportation when you need it?

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22. Do you have clothes that are okay for work school and local weather?

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23. Do you have enough money to meet basic needs and pay bills on time?

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24. Do you save some money for future needs?

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25. Do you have a stable full-time job?

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26. Do you have health insurance for you and your family?

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27. Do you know how to get help if someone in your family needs mental or emotional health care?

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28. Do your family members ever make you feel unsafe?

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29. Can you get good quality childcare if you need it?

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30. Can you get legal help if you need it?

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31. Do you have the skills you need to get the kind of jobs you want?

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32. Do you have a high school diploma or an equivalency diploma (such as a GED)?

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33. Do you know how to get more education if you want it?

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34. Can you say you had no problems with addiction in the last year?

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35. Has your home been tested for lead paint?

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36. Has your child been tested for lead?

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37. Have you checked to see if your home contains lead pipes?

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38. Are the natural resources in your community protected enough that you have access to safe drinking water and enjoyment of green spaces (parks, fields, gardens, etc…)?

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39. Do you have the information you need to vote during elections?

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40. Do you feel connected to your neighborhood community?

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41. Do the youth in your life have access to programs and services that support success in the classroom, including access to basic needs?

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42. Do you know where to go in your community to learn about programs that can help your family (such as food, transportation, shelter, recreation, etc.)?

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43. Do you have access to free arts and culture programs in your community?

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44. What needs do you have that are not listed above?

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45. What type of organization referred you to Imagination Library?

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