1. Instructions

With your help, HRDC can continue providing programs and services to assist low income families and individuals in times of need.   Please take a few minutes to complete this survey.   Your participation helps define the needs in our community and provides the focus for program funding.    No name or other personal information is required.    Please click the correct response.     Only choose one response per question unless multiple responses are requested.   

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* 1. What county do you live in?    If you are not a resident of these counties (do not complete survey)

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* 2.  What is your age?

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* 3.  What is your gender?

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* 4. What is your ethnicity?  Provide multiple responses if they apply.

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* 5. What is your marital status?

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* 6. What is your highest level of education?

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* 7. Are you a veteran?

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* 8. What best describes your present housing situation?

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* 9. What barriers have prevented you from getting and keeping housing?

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* 10. How many times have you moved in the past 12 months?

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* 11. Are you or anyone in your home disabled?

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* 12. How many people reside in the home?

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* 13. How many children under 12 years of age are in your home?

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* 14. Is your home unsafe, and or in need of repairs?  If so, identify the problems.  Provide multiple responses if they apply.

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* 15. Please indicate all types of housing assistance you currently receive.    Provide multiple responses if they apply.

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* 16. What best describes your primary mode of transportation?

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* 17. Have you or a member of your household received transportation services?  If so identify the services you have received.   Provide multiple responses if they apply.

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* 18. Identify the transportation barriers that you have experienced in the last 12 months?   Provide multiple responses if they apply.

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* 19. What best describes your current employment status?

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* 20. If unemployed, how long have you been unemployed?

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* 21. If you are underemployed, (working too few hours), or overqualified for the work you do?  Indicate why.   Provide multiple responses if they apply.

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* 22. Are you a student?  If yes, identify classification.

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* 23. Are you currently participating in an Employment and or Training Program?

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* 24. Are you currently using child care services in your community?  If so, what best describes your childcare provider.

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* 25. If you have children, but are not using childcare services what are the barriers that prevent you from doing so?  Provide multiple responses if they apply.

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* 26. Do you have a child or children who require after school care?   If so, what barriers prevent you from enrolling them?   Provide multiple responses if they apply.

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* 27. Are you aware that your children may be eligible for “Best Beginnings Scholarship” support for child care or after school programs?

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* 28. If you have someone in your household who requires elder care, but are not currently receiving financial assistance, identify the barriers you are facing?  

 

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* 29. Have you or a household member gone without food in the last 12 months?  If so, what barriers prevented you from obtaining food?  Provide multiple responses if they apply.

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* 30. Where do you go for emergency food assistance?

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* 31. Do you prepare a monthly spending plan?  If so how well do you stay within your budget?

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* 32. Do you have a checking or savings account?  If not, what prevents you from opening an account?  Provide multiple
responses if they apply.

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* 33. Do you file taxes every year and or receive an annual tax refund? 

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* 34. Do you have an emergency savings fund?

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* 35. Do you have health insurance coverage?   If so, what best describes your present coverage?

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* 36. Have you seen a healthcare professional in the last 12 months?  If so, identify your caregiver.   Provide multiple responses if they apply.

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* 37. In the past year, have you or a member of your household gone without your prescriptions or medications because you couldn’t afford them? If so what best describes why.

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* 38. What programs do you and or a member of your household currently participate in?   Provide multiple responses if they apply.

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* 39. If available would you participate in family support programs that help reconnect families?  If so what types of programs would be of interest to you?  Provide multiple responses if they apply?

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* 40. If you or a member of your family were experiencing any of the following problems,   would you know where to go for help?   If the answer is yes, click on the resources you know about.     Provide multiple responses if they apply.

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* 41. Are there any other services or assistance that you require that has not been identified on this survey?   List by level of importance.

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* 42. This is the end of the questionnaire.   Thank you for taking the time to complete the survey.   Your participation helps us to deliver the types of programs and services that you and your community need.   If you have additional comments, enter them here.

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