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* 1. County

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* 2. Age

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* 3. Marital Status

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* 4. Race

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* 5. Number in Household

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* 6. Household Income

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* 7. Gender

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* 8. Number in household under age 18

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* 9. Number in household age 60 and older

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* 10. Is anyone living in your household a veteran, active duty or retired/discharged?

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* 11. Do you currently have health insurance?

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* 12. Do any adults or children living in your household not have health insurance?

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* 13. Was there a problem for anyone in your household during the last 12 months when they needed vision, medical, dental, mental health care and/or prescription medication but did not get it? Check the box for each service that was not received.

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* 14. List the three (3) most important needs in your community.

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* 15. How important is this service to your household? Please check one answer for each service.

  Extremely Important Very Important Somewhat Important Not Important Does Not Apply to My Household
Child Care
Elder Care - in home
Disability Services
After School Activities
Financial Education - budgeting, credit counseling, etc.
Tutoring
Domestic Violence/Sexual Assault Services
Free Legal Services
Clothing
Transportation
Medical, Dental and/or Vision Care
Living Wage Job (more than minimum wage)
Help Paying Bills
Mental Health Services
Food (help having enough food)
Hospice
Housing
Home Repair & Maintenance
Paying for Prescriptions
Post-Secondary/College Education
Drug/Alcohol Treatment and/or Counseling
Education
Senior Services - companionship, transportation, etc.

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* 16. Have you or anyone in your household experienced any physical, verbal or sexual violence?

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* 17. Check the highest level of education you have completed.

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* 18. Does any adult in your household need additional training to become employed or to get a better job?

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* 19. What is your employment status?

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* 20. Which of these has been a source of income for anyone in your home during the last 12 months? Check all that apply.

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* 21. Has getting or keeping a job been a problem for you or anyone in your home in the last 12 months?

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* 22. If yes, what are the major challenges in getting or keeping a job? Check all that apply.

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* 23. Do you have reliable transportation?

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* 24. In the past 12 months, which of the following has your household experienced?

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* 25. Did any of the following challenges happen to you or to your household during the last 12 months?

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* 26. In the past 12 months, have you or anyone in your household...(check all that apply)

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* 27. If you received help with food, which of the following did your household use in the last 12 months? Check all that apply.

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* 28. Where did you sleep last night?

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* 29. Have any of the following housing situations happened to you in the last 12 months? Check all that apply.

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