NORWESCAP Poverty Survey 1. Question Title * 1. What town or township do you live in? Question Title * 2. What County do you live in? Hunterdon Somerset Morris Sussex Warren Other (please specify) Question Title * 3. Total number of people who live in your household including yourself? Please complete each question for every member of your household including yourself. Question Title * 4. Self Male Female Question Title * 5. Your Age 15-18 19-25 26-55 55+ Question Title * 6. Do you have health insurance? Yes No Question Title * 7. Do you have prescription coverage? Yes No Question Title * 8. Spouse/ Partner - (If you don't have a spouse or partner, but have children, skip to question 12. If no other persons live in the household, skip to question 40.) Male Female Question Title * 9. Spouse/ Partner age 15-18 19-25 26-55 55+ Question Title * 10. Does your spouse/ partner have health insurance? Yes No Question Title * 11. Does your spouse/ partner have prescription coverage? Yes No Question Title * 12. Child - (If this is your only child, but there is another person living in your household, skip to question 32. If no other persons, skip to question 40.) Male Female Question Title * 13. Child's age 0-6 7-14 15-18 19+ Question Title * 14. Does the child have health insurance Yes No Question Title * 15. Does the child have Prescription Coverage? Yes No Question Title * 16. Does the child attend childcare Yes No Question Title * 17. Child - (If there are no other children, but there is another person living in your household, skip to question 32. If no other persons, skip to question 40.) Male Female Question Title * 18. Child's age 0-6 7-14 15-18 19+ Question Title * 19. Does the child have health insurance Yes No Question Title * 20. Does the child have Prescription Coverage? Yes No Question Title * 21. Does the child attend childcare? (If there are no other children, but there is another person living in your household, skip to question 32. If there are no other persons, skip to question 40.) Yes No Question Title * 22. Child Male Female Question Title * 23. Child's age 0-6 7-14 15-18 19+ Question Title * 24. Does the child have health insurance Yes No Question Title * 25. Does the child have Prescription Coverage? Yes No Question Title * 26. Does the child attend childcare Yes No Question Title * 27. Child - (If there are no other children, but there is another person living in your household, skip to question 32. If there are no other persons, skip to question 40.) Male Female Question Title * 28. Child's age 0-6 7-14 15-18 21+ Question Title * 29. Does the child have health insurance Yes No Question Title * 30. Does the child have Prescription Coverage? Yes No Question Title * 31. Does the child attend childcare Yes No Question Title * 32. Other member in the household - (If there no other members, skip to question 40.) Male Female Question Title * 33. Other Member age 15-18 19-25 26-55 55+ Question Title * 34. Does the other member have health insurance? Yes No Question Title * 35. Does the other member have prescription coverage? Yes No Question Title * 36. Other member in the household Male Female Question Title * 37. Other Member age 15-18 19-25 26-55 55+ Question Title * 38. Does other member have health insurance? Yes No Question Title * 39. Does other member have prescription coverage? Yes No Question Title * 40. Which one of these applies to your living situation? Married Widowed Single (never married) Living together Separated Divorced Question Title * 41. Which one of these do you consider yourself? Hispanic or Latino Black or African American White Asian Multiracial Question Title * 42. What is the primary language spoken in your home? English Spanish Other (please specify) Question Title * 43. Are you currently a student? Yes No Question Title * 44. What is the highest level of education you have completed? Grade 8 Grades 9-12 (but did not graduate) GED High School Diploma Some College Credits A Vocational or Trade School 2-Year Degree/Associate’s Degree 4-Year Degree/Bachelor’s Degree Post Graduate Degree Question Title * 45. What is your housing status? Rent Own Currently Homeless and/or living with friends/relatives Question Title * 46. If you rent… Do you live in public housing? Yes No I don't rent Question Title * 47. If you rent, do you receive Section 8, rental assistance, or a housing voucher? Yes No I don't rent Question Title * 48. If you own… Do you have a mortgage? Yes No I don't own a home Question Title * 49. If you own... Have you missed any payments in the past year? Yes No I don't own a home Question Title * 50. If you own.. Have foreclosure procedures started at any time in the past year? Yes No I don't own a home Question Title * 51. If you have been homeless… or living with friends/relatives in the last year…have you lived in a shelter or transitional housing? Yes No I have not been homeless Question Title * 52. If you have been homeless or living with friends/relatives in the last year…have you lived mostly in car or on the street? Yes No I have not been homeless Question Title * 53. In the past twelve months, has your utility service (water, gas, electricity, telephone, heat) been shut off or received notice of shut off? Yes No Question Title * 54. Are any of these things a problem in your neighborhood? Noisy Neighbors Garbage or Litter Crime None of these apply Other (please specify) Question Title * 55. How do you feel about living in your neighborhood? (Select One) Very Satisfied Fairly Satisfied Neutral Slightly Dissatisfied Very Dissatisfied Question Title * 56. What title best describes your job or employment area? Administrative Assistant/Clerk Healthcare/Hospital Child Care Housekeeping/Maintenance Construction Worker/Laborer Management/Professional Service Retail/Working in Store Food Service Warehouse Other (please specify) Question Title * 57. In the past two years, did any of the following happen to you? (Select all that apply) Was laid-off from a job Had hours reduced from work schedule Business closed Lost health insurance None of these apply to me Question Title * 58. How many people in your household are: number of veterans Veterans? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+ Veterans? number of veterans menu Disabled? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+ Disabled? number of veterans menu Question Title * 59. How do you get around? (Select only one) Own car Take bus/County Transportation Get rides from family and friends Taxi Walk or Bike Question Title * 60. Do you actively use the Internet? Yes No Question Title * 61. Have you ever applied for help from NORWESCAP or other community agency using the Internet? Yes No Question Title * 62. Were you involved in any of the following community activities this year? (Select all that apply) I voted I volunteered at a community organization I was active at my Church I was active in my child’s school/PTA I was active in my neighborhood (Block Watch, etc.) I was active in the building where I live (Tenants Association) I wrote to the newspaper or government/elected official to express my opinion) I attended a public meeting (town council, freeholder meeting, school board) Question Title * 63. What are your three (3) greatest needs that are not being met. Affordable housing/Safer place to live/Home of my own Car/More reliable transportation Childcare that is affordable Dental care Food Health care Job Training/Better Job/Employment Opportunity Mental Health Care/Treatment Substance Abuse/Alcohol Abuse Treatment Other (please specify) Question Title * 64. Which of the following do you have? (Select all that apply) Checking Account Savings Account Pension or Individual Retirement Account Credit Cards Prepaid Debit Card None of the Above Question Title * 65. Do you pay for check cashing services? Yes No Question Title * 66. Have you filed for bankruptcy within the past three years? Yes No Question Title * 67. Have you applied for and/or received the Earned Income Tax Credit (EITC)? Yes No Not sure/ Don't know about EITC Question Title * 68. If you do know about Earned Income Tax Credit (EITC), but haven't filed for it, can you tell us why? Didn't know how to file a tax return Didn't file a tax return at all Afraid to file a tax return Question Title * 69. Do you have income from employment in your household? (If check no then go to question 71) Yes No Question Title * 70. If you have income from employment in your household, what is the total household income from employment? (Please include all household members income) $0-$10,000 Year $10,001 - $20,000 Year $20,001 - $30,000 Year $30,001 - $40,000 Year $40,001 - $50,000 Year $50,001 - or More per year Question Title * 71. Is anyone in the household receiving unemployment benefits? (If you check no, then skip to question 73.) Yes No Question Title * 72. If people in the house are receiving unemployment benefits, what is the amount which they are receiving? $100-$200 Week $201-$300 Week $301-$400 Week $401-$500 Week $501-$600 Week Other $ Question Title * 73. Is anyone in the household receiving child support? (If you check no, then skip to question 75) Yes No Question Title * 74. If there is someone in the house receiving child support, what is the monthly amount? $100-$250 Monthly $251-$350 Monthly $351-$450 Monthly $451-$550 Monthly $551-$650 Monthly $651-$750 Monthly $751-$850 Monthly $851 and Higher-Monthly Question Title * 75. Is anyone in the household receiving Social Security, SSI, or SSD? (If you check no, then skip to question 77.) Yes No Question Title * 76. If there is someone in the house receiving Social Security, SSI, or SSD, what is the amount? $100-$500 Monthly $501-$800 Monthly $801-$1000 Monthly $1001-$1200 Monthly $1201-$1400 Monthly $1401-$1600 Monthly $1601-$1800 Monthly $1801 and Higher-Monthly Question Title * 77. Is anyone in the house receiving Welfare, Cash Assistance, TANF or General Assistance (GA)? (If you check no, then skip to question 79.) Yes No Question Title * 78. If there is someone in the house receiving Welfare, Cash Assistance, TANF or General Assistance (GA), what is the total amount received in the household? $100-$140 Monthly $141-$250 Monthly $251-$350 Monthly $351-$450 Monthly $451-$550 Monthly More than $550 Monthly Question Title * 79. Is anyone in the household receiving food stamps? (If you check no, then skip to question 81.) Yes No Question Title * 80. If someone in the house is receiving food stamps, what is the total amount received in the household? $10-$100 Monthly $101-$200 Monthly $201-$250 Monthly $251-$300 Monthly $301-$350 Monthly $351-$400 Monthly $401-$450 Monthly More than $451 Question Title * 81. Is anyone in the household receiving pension benefits? (If you check no, then skip to question 83.) Yes No Question Title * 82. If someone in the house is receiving pension benefits, how much is the total amount? $100-$500 Monthly $501-$1000 Monthly $1001-$1500 Monthly $1501-$2000 Monthly $2001-$2500 Monthly More than $2501 Question Title * 83. Is anyone receiving any other income in the household? (If you checked no, then skip to question 86.) Yes No Question Title * 84. If yes, what type? Veteran's Benefits Family/Friends Other (please specify) Question Title * 85. If someone in the house is receiving any other income, what is the total amount of the income received in the household? $100-$200 Monthly $201-$300 Monthly $301-$400 Monthly $401-$500 Monthly $501-$600 Monthly $601-$700 Monthly $701-$800 Monthly More than $801 Monthly Question Title * 86. How much money do you think you need for your household bills each month? Question Title * 87. In your opinion, why do you think that people are struggling to get by? (Select One) Because they are unlucky/ Bad breaks Because they lack motivation/ Work ethic Drug/alcohol abuse Health issues Welfare/Government system Because they lack education/jobs/training Can't change/ or it's the way people grew up Employment-not enough living wage jobs Mental health issues Other (please specify) Question Title * 88. If money is tight in your budget, what do you do to make ends meet? (Select all that apply) Not pay a bill Seek government assistance Borrow money from relatives or friends Move in with others/share living expenses Work additional hours Find other work Seek assistance from community action agency Other (please specify) Question Title * 89. Looking toward next year, how do you think things will be for you and your family? About the same as this year I think things are going to get better I think things are going to get worse Question Title * 90. If you receive or have received any services from NORWESCAP, please mark each service that you received. Arthur & Friends Greenhouse Project Backpack Food Program Career and Life Transitions Center for Women Cancer Screening/CEED Child Care Voucher Circles ™ Initiative Circles ™ College Community Meals Individual Development Account - matched savings Early Head Start Family Self Sufficiency Financial Literacy - Budgeting Family Loan Program Energy Assistance (LIHEAP) Food Bank Head Start Healthy Families (TIP) Housing/Homelessness Assistance Minor Home Repair Heating System Improvement Phillipsburg Family Success Center SHIP State Health Insurance Program Summer Feeding/Nutrition Program Skylands RSVP (Volunteer) Utility (Electric) Assitance Weatherization (WIC) Women, Infants & Children Supplemental Food Program Volunteer Income Tax Assistance Other (please specify) Question Title * 91. If you could change one thing about your life to make it better, what would it be? Thank you for your participation.All answers are confidential. We appreciate your help! Done