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* 1. What city do you live in?

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* 2. How many people live in your household?

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* 3. What is your age?

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* 4. How many people living in your household are each of the following ages?

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* 5. Are you Female or Male?

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* 6. What languages do you speak at home?

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* 7. What is your race/ethnicity? Check all that apply.

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* 8. What is your PRIMARY mode of transportation? Choose One:

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* 9. In the past 12 months, has anyone in your household experienced any of the following problems with transportation? Check all that apply.

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* 10. If you had an unexpected $400 expense this month, would you have enough income or savings to cover that?

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* 11. If you were not able to pay the $400 out of income or savings, what would you do? Choose one:

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* 12. What are the top three things you’ve had trouble with this year? Please number your 1st, 2nd, and 3rd top needs. Consider the list below as possible examples.

Child care
Financial assistance
Transportation
Health care
Utility assistance
Dental care
Senior citizen services
English (ESL) Classes
Documentation Status
Safety/crime prevention
Legal assistance
Substance abuse assistance
Housing Assistance
Adult education/GED programs
Mental health services
Parenting classes
Domestic violence assistance
Youth programs/tutoring
Food assistance
Job training
Veterans services
Animal Care
Employment

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* 13. Did you get any help or service on those 3 needs?

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* 14. Do you work for pay?

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* 15. About how much money will you earn from jobs/work this year?

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* 16. If you do work, do you have more than one job?

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* 17. Do you work full-time? (40 hours/week)

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* 18. Do you work seasonal or temporary jobs?

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* 19. Were you working last week?

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* 20. What type of job do you have?

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* 21. Does your job provide health insurance?

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* 22. Do you receive any of these:

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* 23. Do any of these things prevent you from working? Check all that apply.

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* 24. Many families receive help from various sources. How much, if anything, did your family receive from the following last month?

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* 25. Do you know of any services that you qualify for but have decided not to use?

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* 26. If you qualify for a service but don’t use it, why?

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* 27. In the past 12 months, have any of these things happened to you?

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* 28. Remember that your answers are completely confidential. Thinking of everyone in your household, what will be your household’s total income this year?

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* 29. What is your housing status?

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* 30. Which of the following best describes your home?

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* 31. Do any of these apply to the condition of your home? Check all that apply:

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* 32. Have you ever been homeless for a week or longer— that is, you slept in a place where people weren’t meant to sleep, or slept in a homeless shelter, or didn’t have a regular residence in which to sleep?

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* 33. Do you feel worried about having stable housing in the near future? (For example, because of affordability, eviction, or health problems.)

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* 34. Have you experienced any of the following problems related to housing in the past 12 months? Check all that apply:

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* 35. If you rent, have you had trouble getting your landlord to make needed repairs?

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* 36. When moving out of a rented apartment or house, have you ever felt that your security deposit was unfairly withheld?

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* 37. What is your rent/mortgage payment each month?

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* 38. What do you pay for utilities (water, electricity, gas) each month?

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* 39. Do you feel safe in your neighborhood?

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* 40. In the last 6 months, do you know of any violent event that happened in your neighborhood, such as a mugging, fight, or sexual assault?

 
50% of survey complete.

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