Needs Assessment Survey Ver. 3

The Northeast Flood-Affected Region, through Carlton County Public Health & Human Services, has received a grant from the State of Minnesota - Minnesota Recovers Task Force to make sure that the long-term recovery needs of residents in Carlton, Aitkin, Pine, and St. Louis Counties who were affected by the flooding in June 2012 are taken care of. Please help us by answering these questions about the ways that you might have been affected. Included are questions about your home, your possessions, your yard, stress, your finances and your health. Thank you.

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* 1. Who will you be answering for?

A. Primary residence

B. Secondary or vacation home

C. A home you own but rent out

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* 2. Do you have friends and/or family affected by the June 2012 floods?

A. I have family/close friends significantly affected by the June 2012 floods

B. I have family/close friends moderately affected by the June 2012 floods

C. I have family/close friends affected a little by the June 2012 floods

D. I don't have any family/close friends affected by the June 2012 floods

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* 3. Did you have to move because of damage caused by the June 2012 floods?

A. Yes, permanently

B. Yes, temporarily, and we have not yet returned

C. Yes, temporarily, but we have returned to our home within a month

D. Yes, temporarily, but we returned to our home after more than a month

E. No

Living Space and Structure:

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* 4. Was your living space or building structure damaged in the June 2012 floods? (Include damage to key systems including electrical, heating, and water).

A. Nearly or completely destroyed

B. Major damage (more than $10,000 to repair or return to pre-flood conditions)

C. Significant damage (between $2,000 and $10,000 to repair or return to pre-flood conditions)

D. Minor damage (less than $2,000 to repair or return to pre-flood conditions)

E. No living space damage

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* 5. Is part of your home/apartment that you use as living space, or its structure still not repaired or returned to pre-flood conditions?

A. Fully repaired or returned to pre-flood conditions

B. Part of the home that we use as a living space still needs work worth more than $2,000

C. Part of the home that we use as a living space still needs work worth $2,000 or less

D. Not applicable

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* 6. Did the flood destroy or damage your possessions?

A. Major loss. We needed more than $2,000 to repair or replace possessions damaged in the flood

B. Moderate loss. We needed between $500 and $2,000 to repair or replace possessions damaged in the flood

C. Minor loss, We needed less than $500 to repair or replace possessions damaged in the flood

D. We had no damage to our possessions

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* 7. Is part of your home/apartment that you don't use as a living space (storage or utility space) still not repaired or returned to pre-flood conditions?

A. Fully repaired or returned to pre-flood conditions

B. Part of the home that we don't use as living space still needs work worth more than $2,000

C. Part of the home that we don't use as living space still needs work worth $2,000 or less

D. There was no damage to parts of our home that we don't use as living space

The Rest of Your Home and Yard:

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* 8. What is the condition of your outside space? (Yard or common outside space at an apartment building).

A. The outside space is fully recovered and has improvements that will help prevent damage if another flood occurs.

B. The outside spaces is as good as it was before the June 2012 floods, but needs improvements to prevent damage if another flood occurs

C. The outside space is as good as it was before the June 2012 floods, and does not need improvement

D. The outside space is mostly recovered from the June 2012 floods, but could use additional work

E. The outside space still needs substantial work to repair damage caused by the June 2012 floods

F. The outside space had no damage or was unaffected by the June 2012 floods

Moisture and/or Mold:

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* 9. Is moisture and/or mold more of a problem in your home due to the June 2012 floods? (check all that apply).

A. I have a noticeable increase in moisture

B. I have a noticeable increase in mold

C. My moisture/mold is manageable (I can clean it)

D. My moisture/mold is difficult to manage/clean

E. My moisture/mold is impossible to manage/clean

F. The June 2012 floods had no impact on moistutre/mold in my home

Stress and Emotional Health:

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* 10. Have you felt stress because of the June 2012 floods?

A. I did at the time, but not recently

B. I do from time to time

C. Frequently

D. Never

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* 11. Do you have any emotional health concerns caused or made worse by the June 2012 floods?

A. The June 2012 floods have created emotional health concerns for me

B. The June 2012 floods have made it harder for me to deal with my existing emotional health concerns

C. No

Since the June 2012 Floods, Have You Noticed a Change in:

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* 12. Concentration

A. Yes

B. No

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* 13. Feeling nervous and/or anxious

A. Yes

B. No

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* 14. Sleeping habits

A. Sleeping more

B. Sleeping less

C. No change

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* 15. Frustrated and/or angry

A. More

B. Less

C. No change

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* 16. Since the June 2012 floods, have you seen relatives and/or friends:

A. More often

B. About the same

C. Less often

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* 17. Since the June 2012 floods, how much are you able to get exercise?

A. More

B. About the same

C. Less

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* 18. Since the June 2012 floods, how is your physical health? (back pain, shoulders, heart, etc.).

A. I have new physical body health concerns

B. I have increased physical body health concerns

C. I have decreased physical body health concerns

D. I have no physical body health concerns

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* 19. How did the June 2012 floods affect your debts and the amounts you owe to others?

A. We now have debts from the floods that we can't pay

B. We now have debts from the floods that we are having difficulties paying

C. We now have debts from the floods that are significant, but manageable

D. We now have debts from the floods, but they are manageable

E. We have no debts caused by the floods.

Savings and Retirement:

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* 20. Due to the June 2012 floods did you have to spend money from your savings and/or retirement?

A. We had to take a considerable amount ($10,000 or more) out of our savings and/or retirement to pay for flood repairs and related expenses

B. We had to spend between $2,000 and $10,000 of our savings and/or retirement to pay for flood repairs and related expenses

C. We had to spend under $2,000 from our savings and/or retirement to pay for flood repairs and related expenses

D. We did not have to spend money from our savings and/or retirement to pay for flood repairs and related expenses

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* 21. Did you receive financial assistance from federal, state, local government, private, or non-profit agencies to help recover from the June 2012 floods?

A. Yes, $2,000 or more

B. Yes, less than $2,000

C. No, I did not receive financial assistance

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* 22. If you received assistance, what kind was it? (Check all that apply).

A. Federal Disaster/SBA loan

B. State QuickStart loan

C. State assistance for renters

D. Local recovery assistance from Long Term Recovery Committees, United Ways, Catholic Charities, the Salvation Army, or local/regional groups?

E. Financial assistance from friends and/or family

F. Not applicable

Other (please specify)

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* 23. Did you receive any services to help make repairs to your home in additional to financial assistance? What kind? (Check all that apply).

A. Volunteer help

B. Advice and case management

C. Help from a soil and water district

D. None

Other (please specify)

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* 24. Did you receive any stress management services?

A. Yes

B. No

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* 25. If yes, what kind? (Check all that apply).

A. Medical

B. Emotional and/or counseling

Other (please specify)

Finally, please answer some demographic questions to help us understand future needs across the region:

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* 26. What is your housing status now?

A. Own your home

B. Rent

C. Homeless

D. Live with friends or family

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* 27. Which county do you live in?

A. Aitkin

B. Carlton

C. Pine

D. St, Louis

E. Lake

F. Douglas (Wisconsin)

Other (please specify)

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* 28. What is your gender?

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* 29. Are you a veteran?

A. Yes

B. No

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* 30. How old are you?

A. 18-24

B. 25-34

C. 35-44

D. 45-54

E. 55-64

F. 65+

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* 31. How many people are in your household? (Including yourself).

A. 1 (Just yourself)

B. 2

C. 3

D. 4

E. 5 or more

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* 32. How many people are in your household who are under the age of 18?

A. 1

B. 2

C. 3

D. 4

E. 5 or more

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* 33. There are two reasons you might want us to contact you.

Please include contact information if you would like us to contact you about your current situation and/or talk about your needs. (Please include name, phone number and/or email address, and the best time to contact you).

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* 34. The other reason:

Please include your contact information here if you'd like to share your story of rebuilding after the June 2012 floods. (Please include name, phone number and/or email address, and the best time to contact you).

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* 1. Who will you be answering for?

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* 2. Do you have friends and/or family affected by the June 2012 floods?

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* 3. Did you have to move because of damage caused by the June 2012 floods?

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* 4. Was your living space or building structure damaged in the June 2012 floods? (Include damage to key systems including electrical, heating, and water).

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* 5. Is part of your home/apartment that you use as living space, or its structure still not repaired or returned to pre-flood conditions?

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* 6. Did the flood destroy or damage your possessions?

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* 7. Is part of your home/apartment that you don't use as a living space (storage or utility space) still not repaired or returned to pre-flood conditions?

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* 8. What is the condition of your outside space? (Yard or common outside space at an apartment building).

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* 9. Is moisture and/or mold more of a problem in your home due to the June 2012 floods? (check all that apply).

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* 10. Have you felt stress because of the June 2012 floods?

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* 11. Do you have any emotional health concerns caused or made worse by the June 2012 floods?

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* 12. Concentration

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* 13. Feeling nervous and/or anxious

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* 14. Sleeping habits

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* 15. Frustrated and/or angry

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* 16. Since the June 2012 floods, have you seen relatives and/or friends:

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* 17. Since the June 2012 floods, how much are you able to get exercise?

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* 18. Since the June 2012 floods, how is your physical health? (back pain, shoulders, heart, etc.).

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* 19. How did the June 2012 floods affect your debts and the amounts you owe to others?

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* 20. Due to the June 2012 floods did you have to spend money from your savings and/or retirement?

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* 21. Did you receive financial assistance from federal, state, local government, private, or non-profit agencies to help recover from the June 2012 floods?

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* 22. If you received assistance, what kind was it? (Check all that apply).

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* 23. Did you receive any services to help make repairs to your home in additional to financial assistance? What kind? (Check all that apply).

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* 24. Did you receive any stress management services?

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* 25. If yes, what kind? (Check all that apply).

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* 26. What is your housing status now?

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* 27. Which county do you live in?

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* 28. What is your gender?

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* 29. Are you a veteran?

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* 30. How old are you?

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* 31. How many people are in your household? (Including yourself).

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* 32. How many people are in your household who are under the age of 18?

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* 33. There are two reasons you might want us to contact you.Please include contact information if you would like us to contact you about your current situation and/or talk about your needs. (Please include name, phone number and/or email address, and the best time to contact you).

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* 34. The other reason:Please include your contact information here if you'd like to share your story of rebuilding after the June 2012 floods. (Please include name, phone number and/or email address, and the best time to contact you).

* 33. There are two reasons you might want us to contact you.

Please include contact information if you would like us to contact you about your current situation and/or talk about your needs. (Please include name, phone number and/or email address, and the best time to contact you).

* 34. The other reason:

Please include your contact information here if you'd like to share your story of rebuilding after the June 2012 floods. (Please include name, phone number and/or email address, and the best time to contact you).