2017 VOICES Membership Needs Assessment Survey

Voices of September 11th is conducting a survey to assess the needs of our membership. Your participation is highly valued and will help guide the development of our programming. The survey includes questions on a variety of topics that may be relevant for you and your family. The survey takes less than 10 minutes to complete, and your responses will be kept confidential.

Please provide us with your most recent contact information so we can keep your informed. If you have questions, contact our office at 203-966-3911. Thank you in advance for your participation!

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* Full Name

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* Home Address

Address *

Address 2

City *

State *

ZIP/Postal Code *

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* Contact Information
All fields are not required

Home Email

Work Email

Cell Phone

Home Phone

Work Phone

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* Age

18-30

31-40

41-50

51-60

61-70

71-80

81 +

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* Gender

Male

Female

Prefer not to answer

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* Have you or your family been directly or indirectly impacted by an act of terrorism or mass violence?

I was directly or indirectly impacted by 9/11

I was directly or indirectly impacted by another act of terrorism or mass violence

No/Not applicable

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* Full Name

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* Home Address

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* Contact InformationAll fields are not required

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* Age

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* Gender

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* Have you or your family been directly or indirectly impacted by an act of terrorism or mass violence?

* Contact Information
All fields are not required