Individual Survey

Thank you for taking the time to answer some questions about your life here in Westmoreland County. By completing this survey, Westmoreland Community Action will be able to better identify the needs of the county's residents and build programing around those needs. Thank you for taking the time to complete our survey!

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* 1. What is your zip code?

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* 2. What is the name of the town or municipality where you reside?

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* 3. What is your Race? (Please select one)

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* 4. What is your ethnicity?

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* 5. What is your gender?

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* 6. What is the primary language spoken in your home?

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* 7. What is your marital status?

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* 8. How many adults are there in your household age 18 or older? Please be sure to include yourself.

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* 9. Number of children in your household. Please include all household members under the age of 18.

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* 10. Age group of the children in your household (check all that apply)

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* 11. Is anyone in the household pregnant?

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* 12. Do the adult(s) in the household have medical coverage?

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* 13. Do the children in the household have medical coverage?

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* 14. Have you ever not taken you or a family member to the doctor because you could not pay the co-pays/deductibles?

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* 15. How often do you feel that you and your family do NOT get enough to eat?

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* 16. How far do you have to travel to the closest major grocery store?

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* 17. Have all the children in your household received all immunizations appropriate for their age?

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* 18. Do you and all the adults in your household receive yearly physicals?

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* 19. Do all of your children receive yearly physicals?

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* 20. Do you and all the adults in your household visit the dentist every six months?

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* 21. Do all of your children (over one year of age) visit the dentist every six months?

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* 22. What best describes your current housing situation?

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* 23. How many times in the past year have you been unable to pay your rent or mortgage?

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* 24. Do you have problems paying to heat your home?

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* 25. What is the general condition of your home?

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* 26. Which, if any, of the following do you have in your home? (Check all that apply)

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* 27. Please indicate the number of people in your household AGES 18 TO 64 highest level of completed education listed below:

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* 28. What is the annual income for your household?

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* 29. What is your source of income? (Check all that apply)

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* 30. What is the furthest any adult in your household travels to work, school, or training?

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* 31. Has any member of your household ever been in jail?

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* 32. What form of transportation do you use MOST OFTEN?

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* 33. How many adults in your household (age 18 and older) have a driver's license?

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* 34. Many families receive services or financial help from area programs or agencies. In the past year, have you or your family received help in any of the following areas? (Check all that apply)

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* 35. Are there any unmet needs you or your family still have?

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* 36. About how long does it take you to travel to the services you use the most?

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* 37. The last time you needed help, how many people did you have to call or talk to before reaching the person who really helped you?

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* 38. Do you have access to the Internet from your home?

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* 39. Do you use your cellphone data as your only source of Internet access?

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* 40. How did you receive this survey?

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