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* 1. What is your zip code?

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* 2. What is your age group?

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* 3. Which of the following ENCAP programs are you currently participating in? Check all that apply.

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* 4. Please choose the response that best describes your opinion of working with ENCAP.

The services that I received met my needs.

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* 5. I feel that ENCAP treats me with dignity and respect.

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* 6. ENCAP staff encourage me to utilize my strengths and resources to better my situation.

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* 7. I find it easy to access ENCAP’s services.

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* 8. I am better able to handle life’s challenges because of ENCAP’s assistance and support.

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* 9. I would recommend ENCAP to a friend or family member.

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* 10. If you rated any of the above statements as 2-Disagree OR 1-Strongly Disagree, please explain why:

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* 11. ENCAP’s goal is to help you reach greater stability and independence. What more could we do to help you or your family reach this goal?

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* 12. How can ENCAP improve or expand its services to help people in need in Douglas and Sarpy County?

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* 13. Please indicate how strongly you disagree or agree with each statement.

I feel a personal sense of responsibility to improve the conditions in my community.

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* 14. I can effectively lead or motivate others to solve problems the community.

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* 15. I have strong social relationships with other people who share my values and interests.

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* 16. I engage in activities that address political, social, local or national issues.

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* 17. I know what actions to take when I see a problem in my community.

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* 18. Are you currently registered to vote in your election district?

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* 19. Which of the following activities would you like to participate in at ENCAP? Check all that apply.

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* 20. What other activities are you interested in that would help increase your awareness and involvement in efforts to improve the community?

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* 21. What recommendations do you have to help you work with ENCAP to become more involved in addressing important community issues?

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* 22. Please provide your name and phone number if you would like more information about any of the above:

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