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* 1. Which county do you live in or represent?

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* 2. What is your zip code?

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* 3. What is your highest level of education?

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* 4. How many dependents are you currently responsible for?

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* 5. What is your role in the community? Mark all that applies.

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* 6. Are you, or have you been, a client of any services offered through Jackson-Vinton Community Action?  If no, please move on to Q8.

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* 7. Is so, which program(s)?  Mark all that applies.

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* 8. Please list your military status.

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* 9. Do you have reliable access to phone service?

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* 10. Do you have reliable access to the internet? If no, skip to question 12.

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* 11. Where do you usually use the internet? Mark all that apply.

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* 12. Are you currently employed?  If no, please go to question 14.

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* 13. What is your employment status?

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* 14. If unemployed, are you currently looking for work? 

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* 15. Please identify your housing situation.

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* 16. If homeless, please note your situation - mark all that apply.

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* 17. In your opinion, please mark the top three most important needs in EDUCATION.   Please take time to review all choices before answering:

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* 18. In your opinion, please mark the top three most important needs in EMPLOYMENT.   Please take time to review all choices before answering:

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* 19. In your opinion, please mark the top three most important needs in HEALTHCARE.  Please take time to review all choices before answering.

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* 20. In your opinion, please mark the top three most important needs in area of HOUSING. Please take time to review all choices before answering:

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* 21. In your opinion, please mark the top three most important needs in TRANSPORTATION.  Please take time to review all choices before answering.

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* 22. In your opinion, please mark the top three most important needs in INCOME and ASSET BUILDING.   Please take time to review all choices before answering:

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* 23. In your opinion, please mark the top three most important needs in CIVIC ENGAGEMENT.   Please take time to review all choices before answering:

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* 24. In your opinion, please mark the top three most important needs in SUPPORT SERVICES.   Please take time to review all choices before answering:

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* 25. In your opinion, please mark the top three most important OVERALL NEEDS  within our communities. Please take time to review all choices before answering.

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* 26. Please identify the most important reason your community needs Community Action.

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