Platte County is responsible for using Community Services Block Grant (CSBG) funds to reduce poverty, improve health and living conditions, and increase the economic self-sufficiency of Platte County residents. Community Builders, Inc. (CBI) is conducting this survey to assist Platte County in determining the needs of the community.

Your identity and answers will be confidential, and we are not asking for your name.  You can skip any questions you want but, if you complete all questions, we can do a better job serving the community's needs.  CBI will provide the summarized results to Platte County, but will not disclose anyone’s individual information.  Please complete and return this survey by August 15, 2017 (you can also complete it online at https://www.surveymonkey.com/r/PlatteCoClient  

THANK YOU FOR YOUR PARTICIPATION!

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* 1. What is your street address ZIP Code?

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* 2. Are you:

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* 3. What is your age?

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* 4. What is your marital status?

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* 5. What is your race?

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* 6. Are you Hispanic or Latino?

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* 7. What is the highest grade that you completed in school?

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* 8. What is your employment status?

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* 9. How many people live in your household on a regular basis?

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* 10. How many children age 5 and under live in your household?

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* 11. How many children age 6 to age 12 live in your household?

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* 12. How many children age 13 to age 17 live in your household?

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* 13. Does anyone in your household have a special need or disability? (Check all that apply)

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* 14. Is there a teenage parent in the home?

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* 15. If there is a single parent raising a child (children) in the household, are both biological parent involved in raising the child (children)?

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* 16. Do you have access to children's books?

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* 17. How often do you read to your child (children)?

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* 18. What is the primary language spoken in the home?

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* 19. How many persons age 65 and older live in your household?

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* 20. Are you a grandparent raising your own grandchild (grandchildren)?

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* 21. How would you describe your living quarters?

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* 22. What are your major housing concerns? (Check all that apply)

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* 23. Do you have any of the following? (Check all that apply)

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* 24. Indicate the areas you or someone in your household receives assistance: (Check all that apply)

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* 25. What is your approximate household annual income? (Include total of everyone living in your household)

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* 26. What changes have you or your household experienced in the past twelve months that negatively affect your income? (Check all that apply)

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* 27. Which of the following services do you need? (Respond by checking the box that best matches your need.)

  Most Needed Somewhat Needed Neutral/Don't Know Not Needed
Help paying rent or mortgage
Affordable housing for seniors
Energy efficiency
Help paying utility bills or deposits
Homeless shelters/services
Public or adequate transportation
Vehicle operation cost assistance
Food and commodity assistance
Nutrition services
Medical care for children
Medical care for adults
Vision services
Dental services
Health insurance coverage
Mental health services
Substance abuse services
Alcohol abuse services
Prescription drug assistance
Support for senior citizens
Help seeking employment
Job training assistance
Education/literacy
Financial counseling
Legal services
Childcare assistance

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* 28. Do you have health insurance?

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* 29. If you have insurance, what type of insurance do you have? (Check all that apply)

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* 30. Does your child (children) have health insurance?

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* 31. Are any of the following things preventing your from receiving assistance with your basic needs?

  A Big Problem Somewhat of a Problem Neutral/Don't Know Not a Problem
I can’t afford fees/cost of assistance
I don't think I am eligible or qualify
I have no transportation
I don’t know where to go for help
My pride gets in the way
The services I need are not available
It didn't work out the last time I tried
I always have to work
My health/disability prevents me
I don't speak English well
My criminal history prevents me
I have no childcare

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* 32. Is there something preventing you from: (Check all that apply)

  No or not needed Cost or lack of insurance Lack of transportation to appointment Lack of childcare during appointment
Receiving Health Care
Receiving Dental Care
Receiving Vision Care

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* 33. Is there something preventing you from being employed? (Check all that apply)

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* 34. Is there something preventing you from having reliable transportation? (Check all that apply)

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* 35. How physically healthy do you consider yourself to be?

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* 36. How important is exercise to your lifestyle?

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* 37. In a typical day, how many microwavable or ready-made meals do you eat?

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* 38. In a typical week, How many times do you eat out?

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