Northwestern Ohio Community Action Commission (NOCAC) is conducting a study of the needs that low-income individuals and families may be experiencing.  Results from this survey will be considered for planning, developing and delivering agency programs, services and activities.
 
Instructions:  
There are 35 questions.  Almost all of the questions are multiple choice.  Please answer each question by checking the appropriate box (or boxes) or typing a response.  The survey will take about 10 minutes.  All surveys will be kept confidential.
 
Participants will have the option of entering a drawing for a $100 gift certificate.  If you choose to participate in the drawing, you will be asked to provide your contact information at the end of the survey.
 
Thank you for participating.  Your feedback is very valuable to us.

* 1. Please identify the county that you live in:

* 2. Your race:

* 3. Your gender:

* 4. Your age (chose only one):

* 5. Your marital status (choose only one):

* 6. Your education (choose only one):

* 7. Your source of income (if you have more than one source of income, choose all that apply):

* 8. Gross household income per month (before taxes are taken out):

* 9. If you have a bank account, is your savings balance:

* 10. Do you have a debit or credit card?

* 11. In the past year, have you used (choose all that apply):

* 12. Have you put money into a retirement plan, through IRA, 401(k) or work pension in the last 6 months?

* 13. Affordable housing in the county is a problem because (choose all that apply):

* 14. Unemployment is a problem in this county because (choose all that apply):

* 15. If you are unemployed or underemployed, it is because (choose the answer that best fits your situation):

* 16. Heating and utility costs are a problem in this county because (choose all that apply):

* 17. Lack of transportation in this county is a problem because (choose all that apply):

* 18. If you have children in your home, what are their ages (choose all that apply):

* 19. Childcare or preschool is an unmet need in this community because (choose all that apply):

* 20. Feeding my family is a problem because (choose all that apply):

* 21. My household benefits from the following food assistance (choose all that apply):

* 22. Housing:  Do you ___?

* 23. How much is your monthly housing payment (rent or mortgage)?

* 24. Is your housing subsidized (HUD or other funding)?

* 25. I am in need of the following home repairs (choose as many as apply):

* 26. How many times have you moved in the last year?

* 27. I have the following health insurance

* 28. Lack of health care is a problem in this county because (choose all that apply):

* 29. Lack of mental health care in this county is a problem because (choose all that apply):

* 30. Lack of dental care in this county is a problem because (choose all that apply)

* 31. I have the following dental Insurance:

* 32. Lack of post high school education and training opportunities in this county are a problem because (choose all that apply):

* 33. Drug or other addictions are a problem in this county because (choose all that apply):

* 34. My household has needs in the following areas (choose all that apply):

* 35. In your opinion the following are missing pieces in your community (choose all that apply):

* 36.
Thank you for your participation.  

(OPTIONAL)
Please provide contact information if you would like to be entered into the drawing for a $100 gift card.
One entry per person.  
Information will be confidential.

NOCAC employees and their immediate family members are not eligible to win the drawing.  

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