Please take a moment to complete this survey - thank you!

By completing this survey, you will help us understand area families' resources and needs.  Your answers will aid community organizations to understand which resources are available, what barriers you face, and what resources are needed.  (Questions with * must be answered)  For an incentive to complete the survey, we will draw one name to receive a $25 VISA gift card.

Your answers are completely confidential.  Thank you.


* 1. In which county do you reside?  If you do not live in one of the counties below, please do not continue to complete this survey.  Thank you.

* 2. From the list of services below, choose five (5) that you think are most needed  in your community.  (Place an X next to those you select)

* 3. Of the problems listed below, choose five (5) that you feel are the most serious to your community. (Place an X by those you select)

* 4. How important is it to you to have an organization such as Rocky Mountain Development Council, Inc. (RMDC) representing your community?

* 5. Whether you are fully employed, unemployed, or underemployed, please choose employment support needs in your community.

* 6. Do either you or your child(ren) have any of these school/education related needs?  (Please check all that apply)

* 7. Please rank the following financial management resource needs. (Rank 1 through 4 with 1 being the highest need)

* 8. Do you have any barriers to good health?

* 9. Where would you go for food assistance?

* 10. Identify the transportation barriers that you or someone in your household have experienced in the last 12 months.  (Provide multiple responses if they apply)

* 11. What programs do you and/or a member of your household currently participate in?  (Provide multiple responses if they apply)

* 12. Do you know where to go for help?  Mark any or all of the following if you would know where to find the service.

The following questions are optional and strictly for data gathering.  Thank you.

* 13. What is your gender?

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

* 15. What is your age?

* 16. My total family income last year was:

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

* 18. How many children age 17 or younger live in your household?

* 19. What was not included in this survey that you feel is important?

* 20. If you would like to be entered to receive a $25.00 VISA gift card, please provide your name and an email address or a phone number.

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