Community Needs Assessment 2018

What City/Town do you live in?

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* 1. What City/Town do you live in?

What County do you live in?

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* 2. What County do you live in?

How long have YOU lived in Gila County?

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* 3. How long have YOU lived in Gila County?

Are you associated with: (Choose 1)

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* 4. Are you associated with: (Choose 1)

Do you have a phone?

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* 5. Do you have a phone?

Do you have a computer?

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* 6. Do you have a computer?

Do you have internet access?

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* 7. Do you have internet access?

Do you or anyone in your household have any of the following NEEDS: (Choose up to 5)

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* 8. Do you or anyone in your household have any of the following NEEDS: (Choose up to 5)

BARRIERS to obtaining basic needs: (Choose up to 3)

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* 9. BARRIERS to obtaining basic needs: (Choose up to 3)

Health care barriers?

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* 10. Health care barriers?

Do you or anyone in your household have any income from: (Check all that apply)

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* 11. Do you or anyone in your household have any income from: (Check all that apply)

Employment barriers? (Choose up to 3)

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* 12. Employment barriers? (Choose up to 3)

Type of Transportation?

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* 13. Type of Transportation?

Transportation barriers?

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* 14. Transportation barriers?

What type of housing do you have?

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* 15. What type of housing do you have?

Housing barriers?

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* 16. Housing barriers?

Age of person completing this survey:

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* 17. Age of person completing this survey:

Marital Status of person completing this survey:

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* 18. Marital Status of person completing this survey:

Race of the person completing this survey:

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* 19. Race of the person completing this survey:

Gender identity of the person completing this survey:

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* 20. Gender identity of the person completing this survey:

Total number in household:

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* 21. Total number in household:

Annual household income:

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* 22. Annual household income:

What is the highest level of education you have completed?  (Choose 1)

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* 23. What is the highest level of education you have completed?  (Choose 1)

Thank you for your time. Your anonymous information will be used to
determine services for Gila County.
Comments/Suggestions:

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* 24. Thank you for your time. Your anonymous information will be used to
determine services for Gila County.
Comments/Suggestions:

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