1.Of this list, which eight (8) issues concern you most in your neighborhood or community?

Need more job training

Not enough jobs

Adult education

Schools and education for children

Safety in schools

Condition of school buildings & facilities

Illiteracy

Language barriers (non-English speaking)

Money management

Need affordable housing

Lack of shelter for homeless families

Food for low-income people

Food for the elderly

Available health care

Emergency services (police, fire, paramedics)

Available mental health care

Services for disabled children and families

Lack of transportation

Roads and street repair

Cost of utilities (gas, electricity, water)

Lack of quality child care

Access to library, bookmobile, etc.

Teen pregnancy

Crime, violence, and drug abuse

Child abuse and neglect

Vacant buildings and run-down houses

Other (please specify)

2.Of this list, which six (6) are the most pressing issues for your family?

Job training

Employment

Educational services for children (tutoring, etc.)

Education for adults (GED, etc.)

Paying necessary bills (gas, water, rent, etc.)

Managing finances

Tax return preparation and filing

Affordable housing

Housing maintenance and repair

Food

Transportation and fuel costs

Available telephone or cell phone

Getting help for personal needs (baths, etc.)

Personal safety

Childcare for infants, toddlers, preschoolers

After school care for school-age children

Summer care for school-age children

In home care for disabled adult

Services for child with disability

Substance abuse

Getting health and medical care

Affordable health insurance

Paying for prescribed drugs

Getting mental health services

Other (please specify)

3.What is your age?

18-25

26-35

36-45

46-55

56-65

66+

4.What is your gender?

Male

Female

5.What is your ethnic group? Check one.

African-American/Black

Hispanic/Latina

American Indian

Asian

Multi-racial

White/Caucasian

Other (please specify)

6.What is the highest level of education you completed? Check only one.

No High School

High School/GED

Technical/Associate's Degree

Bachelor's degree

Master's Degree or higher

7.What is your employment status? Check only one.

Full-time employed

Part-time employed

Self-employed

Unemployed

Retired

Other (please specify)

8.Do you have health insurance? Check one.

Yes - but only for myself

Yes - but only for my children

Yes - for my entire family

No - I do not have health insurance

9.Are you the head of your household?

Yes

No

10.What is your marital status?

Single

Married

Divorced

Widowed

11.Do you receive Public Assistance?

Yes

No

12.Do you receive Social Security Benefits?

Yes

No

13.Do you own or rent your home?

Rent

Own

Homeless

14.Is anyone in your household disabled?

Yes

No

15.What is your annual income range? Check only one.

15,650 or Below

15,651-30,651

30,652-45,652

45,653-60,653

60,654-75,654

75,655-90,655

90,656-105,656

105,657 or above

16.What is your Zip Code?

17.Is there a working computer in your home?

Yes

No