Please tell us about you and your household by completing this CONFIDENTIAL AND ANONYMOUS SURVEY.

 
20% of survey complete.
This survey is being conducted by Waldo Community Action Partners (WCAP). We are a non-profit organization located in Belfast, Maine that works to build strong families and communities. WCAP does this by providing services such as Head Start, fuel assistance, home repair and weatherization, and transportation in the community.   We estimate the survey will take 15 to 20 minutes.
Some of the questions in this survey are personal and we appreciate your willingness to share information with us.  Please know that conducting this survey fulfills WCAP’s contractual obligation to regularly assess the factors that contribute to poverty in its region, as required of all recipients of CSBG funds. WCAP performs this assessment in full every three years and updates some parts annually. The data provided from this survey provides a comprehensive look at the economic and social challenges facing the community. These findings will be incorporated into a Community Needs Assessment.  The assessment will help  identify existing gaps in services for low-income residents as well as opportunities to help them improve their economic, physical, and emotional well-being. 
  
SURVEYS RECEIVED BY FRIDAY, OCTOBER 30 AT 4:30 PM WILL BE INCLUDED IN THE RESULTS. 

Your survey will remain ANONYMOUS unless you choose otherwise.  You may at the end of this survey, choose to provide basic information for the purposes of being entered in a raffle for a $50 Hannaford gift card.  Your answers will be kept CONFIDENTIAL, and your answers will not be publicly identified as yours


If you wish to remain ANONYMOUS, do not provide your name and phone number, but you will not be included in the raffle.
Once again, please know that this survey is completely CONFIDENTIAL and you can choose to remain ANONYMOUS . 

If you have any questions regarding this survey or its intended use, please contact Dorothy Havey at (207) 338-6809, Ext. 216 or dhavey@waldocap.org. Please fill out this survey only once, but feel free to forward this survey to a friend!  If you need a paper copy of the survey, please call WCAP at 338-6809 to request one. 
We are grateful for your participation in this important survey of the Waldo County community.

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* 1. I am responding from the perspective of a: (Please check all that apply)

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* 3. Type of residence (Please check all that apply)

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* 4. How many adults and children live in your household?

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* 5. The number of children in my household that are 5 years or younger

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* 6. The number of children in my household that are ages 6 - 17 years of age

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* 7. Are you a grandparent or family member raising another family member's children?

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* 8. What is your age?

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* 9. What is your race? (Please check all that apply)

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* 10. What language do you primarily speak at home?

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* 11. What is your gender? (Please check all that apply)

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* 12. Do you or a household member identify as part of the LGBTQ community?

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* 13. Are you employed? (Please check all that apply)

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* 14. I am unemployed or underemployed because: (Please check all that apply)

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* 15. Check the highest level of education you have completed:

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* 16. What is your approximate annual household income?

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* 17. Please check which is true for your total household income.

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* 18. Do you have a bank account? (Please check all that apply)

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* 19. During a typical month, I have enough money to pay household monthly bills.

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* 20. I am or a member of my household is a U.S. Veteran or an active U.S. service member.

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* 21. Nicotine used in the last year for household members (Please check all that apply and remember your answers are confidential)

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* 22. Alcohol used in the last year for household members (Please check all that apply and remember your answers are confidential)

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* 23. Cannabis used in the last year for household members (Please check all that apply and remember your answers are confidential)

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* 24. Opioid or other illegal drugs used in the last year for household members (Please check all that apply and remember your answers are confidential)

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* 25. Members in my household have health insurance, ( Please check all that apply)

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* 26. Health insurance is provided by: (Please check all that apply)

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* 27. Does your household have access to the internet? (Please check all that apply)

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* 28. If you have access to the internet, how is it used? (Please check all that apply)

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