The purpose of this survey is to gain a better understanding of how individuals, families and children are faring in terms of having their basic economic, housing, education, health, and social needs met.

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* 1. What is your role?

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* 3. What is your ethnicity?

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* 4. What is your race?

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* 5. How do you identify your gender? 

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* 6. What is your age (in years)?

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* 7. Which best describes your household?

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* 8. How many people live with you?

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* 9. The amount that best represents your annual household income:

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* 10. The number of people in your household between the ages of (Enter the number (1, 2, 3, and so on)  for each category)

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* 11. How many people in your household are disabled?

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* 12. Your highest educational level:

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* 13. Have you experienced any of the following in the last year? Check all that apply.

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* 14. HEALTH CARE is a problem in this area because of (select all that apply) :

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* 15. EARLY CARE AND EDUCATION (for infants up to preschoolers) is a problem because of (select all that apply):

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* 16. EDUCATION/YOUTH is a problem in this area because of (select all that apply):

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* 17. EMPLOYMENT/TRAINING is a problem in this area because of (select all that apply):

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* 18. FINANCIAL MANAGEMENT is a problem in this area because of (select all that apply):

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* 19. FINANCIAL LITERACY is a problem in this area because of (select all that apply):

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* 20. TRANSPORTATION is a problem in this area because of (select all that apply):

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* 21. HOUSING is a problem in this area because of a lack of (select all that apply):

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* 22. FAMILY SUPPORT services are a problem in this area because of (select all that apply):

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* 23. FOOD/NUTRITION is a problem in this area because of (select all that apply):

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