Thank you for your HELP!

By completing this survey, you will help Carson City Human Services research and assess the current trends for Carson City's families' resources and needs. This survey should only take approximately 15-20 minutes to complete. Thank you.

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* 1. Today's Date

Date

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* 2. What is your age?

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* 3. What is your Zip Code

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* 4. What is your highest level of education?

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* 5. Please select all agencies that have, or are helping you.

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* 6. Are you able to work?

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* 7. Which of the following categories best describes your employment status?

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* 8. If unemployed, are you currently looking for work?

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* 9. If you are unemployed, please select the reason(s) why.

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* 10. Would you like help with these job related activities? (Select all that apply)

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* 11. Do you have phone access anytime you need it?

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* 12. What electronics do you own that work?

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* 13. Do you have access to the internet? 

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* 14. If no to Q13 skip this question.
Where do you usually use the internet?

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* 15. What is your housing status?

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* 16. What is your racial or ethnic identity? (Select all that apply.)

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* 17. What language do you mainly speak at home?

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* 18. Which of the following best describes your current relationship status?

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* 19. Do you have minor children?

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* 20. If no to Q19 skip this question.
Are you your child(ren)'s primary caretaker?

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* 21. If you have children or other dependents under your care: What is your family situation?

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* 22. Who provides your child or dependent care? (Select all that apply)

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* 23. If "Self" is selected in Q22, skip this question.
Is your child/dependent care provider someone you can count on?

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* 24. Do you need different child/dependent care help?

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* 25. What type of child/dependent care help do you need?

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* 26. Have you ever lost a job because you did not have dependable child/dependent care?

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* 27. Are you caring for adult children or adult dependents including seniors?

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* 28. Who provides care for the adult children or adult dependents?

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* 29. How many people currently live in your household?

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* 30. Using the answer from previous question, please select the appropriate number of household member to determine income level?

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* 31. Is your household income "more than" or "less than" the income level selected for the number of household members?

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* 32. Which of these monthly bills do you have? (Select all that apply)

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* 33. What type of income do you have? (Select all that apply)

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* 34. If you, or a household member, receives these types of assistance, please select all that apply.

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* 35. Do you, or someone in your home have special needs?

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* 36. If no for Q35 skip this question.
Do you have any of these School/Education related needs? (Select all that apply)

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* 37. In the past 24 months, has your child had to transfer schools because you have moved?

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* 38. Do you have any of the following housing related needs? (Select all that apply)

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* 39. Do you need help in:

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* 40. Have you ever lost a job (or not been able to accept a job offer) because of transportation issues?

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* 41. Do you have any of the following transportation related needs? (Check all that apply)

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* 42. Are you in need of help with any of these things? (Select all that apply)

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* 43. Do you have access to fresh fruits and vegetables?

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* 44. Where do you usually go for, or buy, food?

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* 45. Do you need information on how to cook food for any of these special diets?  (Select all that apply)

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* 46. Do you add daily fresh fruits and vegetables into your diet?

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* 47. If yes, how often?

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* 48. How much fruit do you eat each day?

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* 49. How much vegetables do you eat each day?

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* 50. Do you eat more than one kind of fruit each day?

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* 51. Do you eat more than one kind of vegetable each day?

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* 52. What type of drinks do you have daily? (Select all that apply)

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* 53. Do you run out of food before the end of the month?

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* 54. Do you need information on food nutrition?

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* 55. Do you need to know how to store food so it will last longer?

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* 56. Do you or someone in your household have any of these healthcare needs? (Select all that apply)

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* 57. My Healthcare is a problem because:

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* 58. Do you receive dental care on a regular basis (two times a year)?

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* 59. Are you able to receive care for mental health needs?

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* 60. If NO to Q59 why not?

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* 61. Have you used emergency services in the last 6 months?

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* 62. Do you have health insurance?

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* 63. Are there others in your household who are uninsured?

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* 64. If you have health insurance, who provides your health insurance?

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* 65. Do you have any of these financial needs or problems? (Select all that apply)

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* 66. My information regarding a savings/checking account:

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* 67. I could use help in:

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* 68. Are you a US veteran?

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* 69. If no to Q68 skip this question.
If you are a US veteran are you receiving VA Benefits?

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* 70. If you are not receiving VA Benefits, do you need help?

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* 71. If you are a veteran, do you need assistance with any of the following? (Select all that apply)

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* 72. What have we not asked you about that you feel is important?

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* 73. If you want to be contacted by Carson City Human Service for assistance or resource information please provide your name, phone number, or email address. Your privacy is protected and your information will NOT be shared!

THANK YOU FOR YOUR PARTICIPATION!


Please contact us at:

Carson City Human Services
900 East Long Street
Carson City, NV 89706
775-887-2110 or 775-887-2190
www.gethealthycarsoncity.org
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