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* 1. How serious of a problem do your feel each of the following is in your county?

  1 Not a Problem 2 Somewhat 3 Problem 4 Serious Problem 5 Very Serious Problem
Access to health care
Availability of affordable housing
Affordable child care during, before, and after school hours
Quality of public education in your county
Lack of Early Childhood Education (Pre-K or Head Start)
Availability of job training
Public safety/crime
Incidence of drug and alcohol abuse
Domestic violence
Teen Pregnancy
Availability of adult education (GED, ESL, etc.)
Low wages
Job availability
Availability and access to public transportation
Child health issues (obesity, lead exposure, asthma, etc.)
Incarceration of parents
Access to public assistance (WIC, Food Stamps, Medicaid, etc.)
Services for disabled children
Child abuse/Neglect

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* 2. Please select the top THREE reasons you feel are the primary cause of poverty in your county

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* 3. Has there been a time in the last year when you or someone in your immediate family:

  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 to buy food but couldn't afford to?
Went hungry?
Could not pay the rent?
Had utilities turned off? (Couldn't 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?
Needed a child car seat?
Needed infant supplies?
Needed transportation to and/or from pre-natal care appointment?

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* 4. How good are these services/resources in your county?

  Bad Average Good Don't Know N/A
GED/Adult High School Services
English as a Second Language (ESL) services
Life skills or Parenting classes
Social Services
Mental Health Services
Health Services
Dental Health Services
Nutrition Services
Job Training
Money Management classes
Credit counseling and credit repair
Disability Services and resources
Teen Pregnancy Services and resources
Adult Pregnancy Services and resources
Soonercare

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* 5. Please choose the top 2 service agencies that you or your neighbors use the most:

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* 6. What are 2 or 3 most important things that you believe would improve your household's quality of life?

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* 7. What do you like most about your community?

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* 8. What other programs/services could Head Start offer to better your community?

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* 9. Would you be interested in an Early Head Start Center for infants & toddlers within your community?

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* 10. Ethnicity/Race

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* 11. What is your current employment status?

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* 12. Do you currently have access to any of the following:

  Yes No N/A
Do you have a bank/credit union account (checking or saving)?
Do you have a computer at home?
Do you have an internet connection at home?
Do you have a mobile phone with text capability?
Are you aware of resources available in your community?
Do you know how to access these resources?

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* 13. What county do you live in?

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* 14. What Head Start Center does your child attend?

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