DEMOGRAPHICS
1) County of Residence
No answer
Mercer
Monroe
Summers
2) Town of Residence
3) Gender
No Answer
Male
Female
4) Age
No Answer
18-23
24-44
45-54
55-69
70+
5) Race
No Answer
White
African American
Hispanic
Asian
Native American
Other
Multi-Race
6) People in Household
No Answer
1
2
3
4
5
6
7
8
9+
7) Family Type
No Answer
Single Male
Single Female
Single Parent Male
Single Parent Female
Two Adults at home with Children
Two Adults with no Children
Grandparents with Grandchildren
8) Housing
No Answer
Own Home/Mortgage
Rent Home
Homeless
Other
9) Have Health Insurance
No Answer
Yes
No
10) Source of Family Income (Select up to 2 sources)
No Answer
Employment Only
Employment + Other
Unemployment Insurance
Pension
Social Security
SSI
TANF
Other
None
No Answer
Employment Only
Employment + Other
Unemployment Insurance
Pension
Social Security
SSI
TANF
Other
None
11) Income Level
No Answer
Less than $10,000
$10,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000+
12) Adult Education Level
No Answer
0-8th Grade
9th - 12th Grade, did not graduate
High School Graduate/GED
Some College
2-4 Year College Graduate
13) Number of Children in the Home
No Answer
0
1
2
3
4
5
6
7
8
9+
14) Number of Children in the Home under 5 years old
No Answer
0
1
2
3
4
5
6
7
8
9+
15) Number of Senior Citizens (60+) in the Home
No Answer
0
1
2
3
4
5
6
7
8
9+
16) Number of Disabled in the Home
No Answer
0
1
2
3
4
5
6
7
8
9+
17) Number of Retired People in the Home
No Answer
0
1
2
3
4
5
6
7
8
9+
18) Are you an expecting mother
No Answer
Yes
No
19) Do you speak English as a second language?
No Answer
Yes
No
NEEDS ASSESSMENT
1) When it comes to assistance to help find employment
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
2) When it comes to assistance to help provide food for your family
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
3) When it comes to assistance with providing food for a child care center you operate from your home
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
4) When it comes to assistance with child care for children ages 0-3
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
5) When it comes to assistance with child care for children ages 3-5
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
6) When it comes to assistance with a child care center in your own home
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
7) When it comes to assistance with child care for children ages 5-12
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
8) When it comes to assistance with caring for senior citizens in your own home
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
9) When it comes to assistance with caring for an adult in your own home
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
10) When it comes to assistance with getting clothing for you and your family
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
11) When it comes to assistance with providing meals or other services to a senior citizen
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
12) When it comes to assistance with locating affordable and safe rental housing
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
13) When it comes to assistance with making rent or mortgage payments
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
14) When it comes to assistance with weatherizing your home or emergency home repairs
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
15) When it comes to assistance with paying the ultility bills for your home
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
16) When it comes to assistance obtaining further education or job training
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
17) When it comes to assistance obtaining reliable and safe transportation
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
18) When it comes to assistance obtaining legal aid
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
19) When it comes to assistance obtaining computer and internet access
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
20) When it comes to assistance obtaining mental health counseling for you or your family
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
21) When it comes to assistance obtaining drug and/or alcohol abuse counseling for you or your family
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
22) When it comes to assistance obtaining domestic violence counseling or help for you or your family
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
23) When it comes to assistance obtaining dental care for you or your family
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
24) When it comes to assistance with becoming a homeowner
No Answer
Receiving Assistance
Need Assistance
Do Not Need Assistance
I am Interested
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