Edit Form Please select your property:* Parkview Broadacres Parkview Extension Rocksprings Scattered West (Hill, Chase, Augusta, Macon, etc.) Scattered East (Arch, Dublin, etc.) Nellie B Denney Tower Bonnie Lane Towne View Part I: Household Information 1. Are you an adult 18 years or older?* Yes No 2. Are you the head of household?* Yes No 3. Does anyone in your household have a mental or physical disability?* Yes No Part II: Community / Household Needs 4. How would you rate the following issues for your household? Availability of job training opportunities* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Availability of jobs for adults* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Availability of jobs for youth* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Education* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Availability of affordable, reliable child-care services* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Lack of computer / digital literacy* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Lack of affordable Internet service* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Cost of living* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Income / wages* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Debt* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Financial security* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Availability of financial services* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Availability of financial counseling* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Elderly living assistance (62+)* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Physical health* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Mental health* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Seeking employment with a criminal record* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Obtaining a degree / diploma with a criminal record* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Availability of substance use services* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household Need for substance use treatment* Serious Problem Moderate Problem Not a Problem Does Not Apply to My Household 5. What are the things that make it difficult for you or other adults in your household to find and/or keep work? (check all that apply) Nothing Need affordable childcare Caring for a family member who is sick or disabled Do not speak English well Need computer training Need transportation Need Internet access Need job experience Need job training No job opportunities Do not have a high school diploma / GED Do not have a college degree Disability Criminal record Lack of transportation Other 6. Do you or others in your household have interest in the following? (check all that apply) GED / Adult education Vocational training Increasing income Getting a job Getting a better job Computer training Saving money Eliminating debt 2-year college 4-year college Trade school None Other 7. Do you or another adult in your household have difficulty with any of the following? (check all that apply) Reading Math Writing Speaking English Writing English Using a computer None Other 8. What are the primary health care needs of your household? (check all that apply) Primary health care Pediatric (child) care Prenatal (pregnancy) care Dental care Healthcare education / prevention Nutrition and exercise programs Services to help alleviate stress/anxiety/depression Assistance with daily living for elderly/disabled residents Health screening services Substance use treatment Smoking cessation programs Drinking cessation programs Transportation to healthcare services None Other 9. What is your gender? Identifies as female Identifies as male Other 10. What is your age? (check range) 18-24 25-34 35-44 45-54 55-65 65 or older