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DEMOGRAPHICS

1) County of Residence


2) Town of Residence


3) Gender


4) Age


5) Race


6) People in Household


7) Family Type


8) Housing


9) Have Health Insurance


10) Source of Family Income (Select up to 2 sources)



11) Income Level 


12) Adult Education Level


13) Number of Children in the Home


14) Number of Children in the Home under 5 years old


15) Number of Senior Citizens (60+) in the Home


16) Number of Disabled in the Home


17) Number of Retired People in the Home


18) Are you an expecting mother


19) Do you speak English as a second language?


NEEDS ASSESSMENT

1) When it comes to assistance to help find employment


2) When it comes to assistance to help provide food for your family


3) When it comes to assistance with providing food for a child care center you operate from your home


4) When it comes to assistance with child care for children ages 0-3


5) When it comes to assistance with child care for children ages 3-5


6) When it comes to assistance with a child care center in your own home


7) When it comes to assistance with child care for children ages 5-12 


8) When it comes to assistance with caring for senior citizens in your own home 


9) When it comes to assistance with caring for an adult in your own home


10) When it comes to assistance with getting clothing for you and your family


11) When it comes to assistance with providing meals or other services to a senior citizen


12) When it comes to assistance with locating affordable and safe rental housing


13) When it comes to assistance with making rent or mortgage payments


14) When it comes to assistance with weatherizing your home or emergency home repairs


15) When it comes to assistance with paying the ultility bills for your home 


16) When it comes to assistance obtaining further education or job training


17) When it comes to assistance obtaining reliable and safe transportation


18) When it comes to assistance obtaining legal aid 


19) When it comes to assistance obtaining computer and internet access


20) When it comes to assistance obtaining mental health counseling for you or your family


21) When it comes to assistance obtaining drug and/or alcohol abuse counseling for you or your family


22) When it comes to assistance obtaining domestic violence counseling or help for you or your family


23) When it comes to assistance obtaining dental care for you or your family


24) When it comes to assistance with becoming a homeowner

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