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* 1. What county do you live in?

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* 2. Race or Ethnic Group of each person in your household (list # of persons in each category)

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* 3. Tribal Affiliation (check all that apply)

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* 4. Number of persons in your household (list # of persons)

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* 5. Number of persons in your household - by age (list # of persons in each age category)

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* 6. Household Type (check one)

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* 7. Are you a grandparent raising children?

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* 8. Do you care for an aging parent?

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* 9. Number of  people with disabilities in the household.

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* 10. Number of persons in your household who HAVE health insurance.

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* 11. Where do you live? (select one)

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* 12. What's your Housing Arrangement?

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* 13. How long have you lived at your current residence?

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* 14. Do you feel safe where you live?

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* 15. Have you been homeless in the past 12 months?

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* 16. Number of adults in the household at each completed level of education (list # of persons)

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* 17. Employment Status of adults

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* 18. I work shifts

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* 19. If employed, does your job offer health insurance?

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* 20. If employed, are you satisfied with your current job?

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* 21. What is the source of your income? Check all that apply.

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* 22. Other support (check all that apply)

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* 23. INCOME: The median household income in Beltrami County is approximately $50,525, and is $53,845 in Cass County. Half of the households have more income, and half have less. Would you say your income is :

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* 24. COMMUNITY ASSETS. What do you love about the community where you live?

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* 25. HOUSEHOLD ASSETS. What is going well for you and the people in your household right now?

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* 26. What are the top two or three things that would most help meet the needs of the adults in your household?

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* 27. What are the top two or three things that would most help meet the needs of the children in your household?

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* 28. Where do you get information about help or services that you need? (check all that apply)

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* 29. Are your needs changing from what they were in the past?

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* 30. How do you feel about your finances in the past few months compared to a year ago?

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* 31. How has the Covid 19 Pandemic affected your household?  Are you:

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* 32. EMPLOYMENT SUPPORTS. Do you need help with the following?

  Currently receiving help with this Might need help with this Do not need this- Okay
Getting training or education for the job I want
Paying for clothing or tools for work
Finding a permanent, full-time job at a wage that will support my family
Learning how to interview, write a resume, or complete a job application
Finding employment opportunities for youth ages 16-24

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* 33. Below are some of the reasons people are having trouble getting a job. Are any of these a problem for you?

  Not a problem A small problem A big problem
I have a criminal history
There are no jobs in my field
I need more training
I have a physical or mental disability
I need transportation
I need childcare
The pay is too low for any job I can get

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* 34. FINANCIAL OR LEGAL SUPPORTS. Do you need help with the following?

  Currently receiving help with this Might need help with this Do not need this - Okay
Legal help with divorce or custody issues
Legal help with domestic abuse or restraining orders
Help to solve problems with credit cards and other debt
Help getting financial assistance -- benefits/cash
Help with finding ways to raise my income
Help saving money for the future
Help to fill out tax forms
Getting enough money to meet your basic needs
Dealing with a criminal record that limits opportunities for work or other needs

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* 35. HEALTHY LIVING - HEALTH SUPPORTS. Do you need help with the following?

  Currently receiving help with this Might need help with this Do not need this - Okay
Help applying for Medical Assistance or MN Care
Help getting treatment for a drug or alcohol problem
Help applying for disability support benefits
Finding a good health insurance that is affordable
Finding a doctor, dentist, or counselor (social worker, psychologist, etc) that accepts Medicare, MA, or MN Care
Finding ongoing or emergency mental health care
Getting health care
Getting dental care
Coping with stress or depression

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* 36. HEALTHY LIVING - NUTRITION SUPPORTS. Do you need help with the following?

  Currently receiving help with this Might need help with this Do not need this - Okay
Applying for food support benefits - SNAP/EBT
Applying for WIC (Women Infant and Children) program
Applying for Nutrition Assistance Program for Seniors - NAPS
Applying for Meals on Wheels
Finding a Community Table / Soup Kitchen
Finding a Food Shelf
Applying for Reduced or Free School Lunch
Getting healthy food for the people in our household
Getting enough food for the people in our household
Learning how to stretch our food budget

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* 37. HOUSING SUPPORTS. Do you need help with the following?

  Currently receiving help with this Might need help with this Do not need this- Okay
Help with paying the mortgage or rent
Help with paying damage or security deposits
Help with paying for home heating expenses
Help with energy-related home repairs and improvements such as air sealing, furnace efficiency, insulation for attics/walls, or health and safety measures
Help with household chores, cleaning or small repairs
Help to prevent foreclosure
Help to prevent eviction
Finding Emergency Shelter
Finding safe and affordable housing that meets my/our needs
Finding housing in safe neighborhoods
Getting the landlord to make repairs
Finding safe and affordable rental units
Finding affordable home ownership opportunities

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* 38. Are you or someone you know having trouble maintaining their home and are at risk of homelessness or in a housing crisis?

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* 39. What do you feel is the primary cause of the impending housing crisis?

  Yes No
Bad Choices
Domestic Violence
Transportation Barriers
Lacking ID/documentations
Family Issues
Child Support
No support system
Increase in rent
Sexual Orientation
Lack of money/resources
Lost job/not employed/hours cut
Rental/credit history
Lease not renewed
Eviction
Health Problems
Criminal History
Mental Health Issues

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* 40. What do you feel are the largest barriers to your obtaining or maintaining stable housing?  Please select up to three answers.

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* 41. What resources / services do you feel would be most effective in preventing or ending your or your acquaintance's housing crisis?  Please select up to three answers.

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* 42. What do you feel is the monthly amount of financial assistance you would need to stabilize the housing crisis?  Please check.

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* 43. What LENGTH of financial assistance do you think would be necessary to stabilize the housing crisis?

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* 44. Please Continue from Question 35
PARENTING / HEAD START / CHILDCARE SUPPORTS. Do you need help with any of the following?

  Currently receiving help with this Need help with this Do not need this
Parenting support
Getting information about infant and child development
Finding programs for children from Birth to age 3
Finding preschool programs for children ages 3 to 5
Help with a child with a disability or behavior problem
Help paying for childcare
Finding affordable childcare
Finding childcare you feel is safe and nurturing
Finding childcare that is open when I need it
Finding before and after school program
Finding summer programs for the children

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* 45. Do you receive child care assistance (CCAP) for this child?

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* 46. What is your biggest concern about childcare?

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* 47. TRANSPORTATION SUPPORTS. Do you need help with the following?

  Currently receiving help with this Might need help with this Do not need this - Okay
Getting access to public transportation
Having a reliable car to get to and from school or work
Having transportation to get to medical appointments
Having transportation to get my children to child care or other activities
Having enough money to pay for car insurance, or license tabs
Having enough money to pay for gas
Having enough money to pay for car repairs

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* 48. BUILDING ASSETS

  Yes No
Are you interested in budgeting workshops or workshops about saving money?
Are you interested in learning more about healthy living?
Are you interested in a Home Stretch or home buying workshop?
Would you like to learn more about life skills such as grocery shopping, menu planning, cooking, parenting, etc.?
Are you interested in learning about starting or growing a business?

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* 49. BI-CAP -- HELPING PEOPLE, CHANGING LIVES

  Strongly Agree Agree Somewhat Agree Disagree
Would you recommend the BI-CAP agency to friends and family?
Do you think BI-CAP is an asset in the community?
Do you think it is pretty easy to get to the BI-CAP offices?
Do you think it is fairly easy to get someone at BI-CAP to help with any concerns?

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* 50. Which BI-CAP and other community program services have you used? Please let us know which services, if any, you have used in the past 12 months, and if those services you used were helpful.

  Check if used Check if helpful
Adult Education
Alcohol/Drug Counseling
Appliance Replacement
Budget/Credit Counseling
Child Support Assistance
Domestic Violence Counseling
Early Childhood Education
Emergency Services (for help with rent)
Employment Assistance
Home Ownership Education
Income-based Home Ownership
Information and Referral
Legal Services
Medical Assistance
Mental Health Counseling
NAPS - Senior Nutrition Assistance
Public Health Services
Rental Housing Assistance/Income-based Housing
Energy Assistance
Family Planning or Planned Parenthood
Family Resource Center
Financial Counseling
Food Shelf
Food Support (SNAP/EBT)
Foreclosure Prevention Assistance
Furnace Repair/Replacement
Head Start
Homeless Assistance
Salvation Army
Senior Meal Assistance
Senior Programming
Soup Kitchen
Tax Preparation Assistance
Veterans Services
Vocational Rehabilitation
Weatherization
WIC (Women, Infant & Children)
Youth Training

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* 51. What OTHER things might help you with your current situation?

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* 52. How long have BI-CAP programs been helping you and your household?

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* 53. Are there any other comments, concerns or suggestions that you have that you can share with us? If so, please provide them here:

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