* 1. This survey is completely anonymous, and any identifying information contained within will not be passed on to a third party.  All data gathered by this survey will be used solely by CAPUP for the Comprehensive Community Needs Assessment.  In addition to this survey, CAPUP will be hosting community forums in the coming weeks.  Would you be interested in participating?

* 2. What is your gender identity?

* 3. Which race/ethnicity best describes you? (Please choose only one.)

* 4. In what zip code do you currently live?

* 5. What area do you live in?

* 6. Do you rent or own your house or apartment?

* 7. In which type of housing do you currently live?

* 8. Does your family receive subsidized housing?

* 9. How many people currently live full-time in your household?

* 10. If applicable, how many people currently live part-time in your household?

* 11. For each of the following services, check the category as it applies to you

  unaware aware using this service unsatisfied  don't use this service
Transportation Assistance (includes all public and nonprofit services)
Childcare Services
Food Assistance (Food pantries, Food stamps, etc.)
Emergency and/or Homeless Shelters
Housing Assistance (with rent, utilities, etc.)
Employment Services (resume writing, job training, clothing for interviews, etc.)
Internet Access
Public Libraries
After-School Programs
Educational Opportunities (Community College, Vocational School, etc.)
Affordable Healthcare Services
Counselling or Mental Health Services
Budgeting and Financial Counselling
Law Enforcement and Public Safety
Cultural and Artistic Programs
Disability Services
Veterans' Services
Nutritional Counselling
Drug Rehab
Legal Assistance
Services for Senior Citizens
Water and Environmental Safety

* 12. How important are the following things to your quality of life?

  Check if Not Important Check if Somewhat Important Check if Very Important
Internet Access
Fresh Fruit and Vegetables
A Car
A Computer
A Dishwasher
A Laundry Machine
Job Training
A College Degree
Childcare
Cable
A Smartphone
A Library
A Faith Community
Good Relations with your Neighbors
Extended Family living nearby
Being Politically Active in your Community
Trust in Law Enforcement
Access to Banks/Personal Finance

* 13. Check if any of the following apply to you

* 14. Do you currently use alcohol, medications, or recreational drugs to cope with life challenges?

* 15. During the past 5 years, have you or a family member... (check all that apply)

* 16. If you were to have any legal trouble in the future, from where/whom would you seek help?

* 17. Please check all that apply to you

* 18. If you are currently working, how many hours do you work per week?

* 19. How many minutes is your commute to work?

* 20. How do you normally get to work?

* 21. How many years have you been at your current job/jobs?

* 22. Have you been unemployed in the past 5 years?

* 23. What is the highest level of education you have completed?

* 24. Do you currently have a savings account?

* 25. Which of the following best describes your current relationship status?

* 26. Do you have primary responsibility for a child/children under 18? If not please skip to question #31

* 27. If you have primary responsibility for a child under 18, please check off how likely is it that your children...

  Not Likely Somewhat Likely Fairly Likely Extremely Likely
Will complete high school
Would participate in a program that will help them get better grades
Will attend college or vocational school
Will graduate from college or vocational school

* 28. If you work, or attend school/training, who cares for your child/children while you are away?

* 29. Do you pay for childcare?

* 30. Do you have a child with special needs?

* 31. Does your child's school accommodate their special needs? 

* 32. Do you currently have health coverage? Please check off which type of coverage applies to you.

* 33. In the past 5 years, have you or a member of your household had a medical emergency?

* 34. If you have a medical emergency, where would you seek treatment?

* 35. If you had a less serious medical issue, would you seek treatment?

* 36. Are you currently on a prescription medication for a chronic illness?

* 37. From where do you normally buy groceries?

* 38. Do you currently spend more than 30% of your income on housing costs (rent, utilities, mortgage payments, etc.)

* 39. Do others contribute to paying your housing costs?

* 40. During the past 3 years have you been forced to move for any reason? If so why?

* 41. Thank you for taking our survey... your feedback is important to us, and critical for improving our services to the community. If we missed something above, please take this opportunity to tell us about it.   

* 42. Collected

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