Dear Valued Community Action Customer:

We value your input. Please take a moment to complete this entire survey.  Your responses will allow our agency the opportunity to evaluate our current and future  services offered to you and our community.

Thank YOU for your time and effort!

* 1. What county do you live in?

* 2. What is your household's zip code?

* 3. Are you male or female?

* 4. Are you aged 55 or over?

* 5. Are you married or living with a partner?

* 6. Employment:
Which employment needs could you use help with? (select all that apply)

* 7. Education:
Which education needs could you or a family member use help with? (select all that apply)

* 8. Financial & Legal Issues:
Which financial and/or legal needs could you or your family use help with? (select all that apply)

* 9. Housing:
Which housing needs could you or your family use help with? (select all that apply)

* 10. Food & Nutrition:
Which food and nutrition needs could you or your family use help with? (select all that apply)

* 11. Do you have children (under the age of 18) living with you?

* 12. Child Care & Child Development:
If you have children (under the age of 18) living with you, which child care and/or child development needs could you or your family use help with? (select all that apply)

* 13. Parenting & Family Support:
If you have children (under the age of 18) living with you, which parenting and/or family support needs could you or your family use help with? (select all that apply)

* 14. Transportation:
Which transportation needs could you or your family use help with? (select all that apply)

* 15. Health:
Which health needs could you or a family member use help with? (select all that apply)

* 16. Basic Needs:
Which basic needs could you or your family use help with (select all that apply)...

* 17. Are there any problems or needs that you or your family faced within the last 12 months that you were unable to get help with? (If yes, please list those problems or needs)

* 18. What is ONE thing you would like to see improved in your neighborhood?

* 19. How did you learn about our agency?  (select all that apply)

* 20. What are your sources of household income? (select all that apply)

* 21. In the last 12 months, how has your household's income situation changed?

* 22. What time of day would you prefer to come to one of our locations (offices) for assistance?  (select one)

* 23. What services has your household received from our agency within the last 12 months?  (select all that apply)

* 24. If you know anyone with an incarcerated adult in their family, do they ever talk about particular concerns that could be addressed through...(select all that apply)

* 25. When you think about your adult family, friends, and neighbors, how many of them might say something like "there's too much month at the end of my money" or "where am I going to find money to pay for that?" (select one)

* 26. When you think about your family, friends, and neighbors, how many of them may have difficulties finding or buying enough quality food to provide at least three meals per day? (select one)

* 27. When you have time to rest or are ready to sleep, what kind of issues in your family or neighborhood keep you up?

* 28. If given the opportunity, would you be willing to serve on a local board or committee that represents and makes decisions for families with low-income?

* 29. Customer Satisfaction Survey

  Yes No N/A
I was helped in a timely manner.
I was treated with respect.
The staff were friendly and helpful.
I got the information and/or the services I needed.
I was informed about other agency or community services.
I would recommend your agency to family and friends.

T