2. Part I: Household Information:

4. 1. What is your gender?*

   1. Female
   2. Male
5. 2. What is your age?*

   1. 18-24
   2. 25-34
   3. 35-44
   4. 45-54
   5. 55-64
   6. 65 or older
6. 3. Are you the head of household?*

   1. Yes
   2. No
7. 4. Does anyone in your household have a mental or physical disability?*

   1. Yes
   2. No

9. Part II: Community/Household Needs:

   5. How would you rate the following issues for your household?

11. Availability of job training opportunities*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
12. Availability of jobs for adults*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
13. Availability of jobs for youth*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
14. Education*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
16. Availability of childcare services*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
17. Lack of computer/digital literacy*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
18. Cost of living*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
19. Income/wages*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
21. Debt*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
22. Financial security*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
23. Availability of financial services*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
24. Availability of financial counseling*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
26. Elderly living assistance (62+)*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
27. Physical health*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
28. Mental health*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
29. Seeking employment with a criminal record*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
31. Obtaining a degree/diploma with a criminal record*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
32. Availability of substance abuse services*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household
33. Need for substance abuse treatment*

    1. Serious Problem
    2. Moderate Problem
    3. Not a Problem
    4. Does Not Apply to My Household

35. 6. What are some barriers that make it difficult for you or other adults in your household to find and/or keep work?

37. (Check All That Apply)*

    1. Nothing
    2. Need affordable childcare
    3. Caring for family member who is sick or disabled
    4. Do not speak English well
    5. Need computer training
    6. Need transportation
    7. Need job experience
    8. Need job training

    1. No job opportunities
    2. Do not have a high school diploma/GED
    3. Do not have a college degree
    4. Disability
    5. Criminal record
    6. Lack of transportation
    7. Don't know
    8. Other
39. If "Other" Please Specify:

41. 7. Do you or others in your household have interest in any of the following?

43. (Check All That Apply)*

    1. GED/Adult education
    2. Vocational training
    3. Increasing income
    4. Getting a job
    5. Getting a better job
    6. Computer training
    7. Saving money

    1. Eliminating debt
    2. 2-year college
    3. 4-year college
    4. Trade school
    5. Don't know
    6. None
    7. Other
45. If "Other" Please Specify:

47. 8. Do you or another adult in your household have difficulty with any of the following?

49. (Check All That Apply)*

    1. Reading
    2. Math
    3. Writing
    4. Speaking English
    5. Writing English

    1. Using a computer
    2. Don't know
    3. None
    4. No response
    5. Other
51. If "Other" Please Specify:

53. 9. What are the primary healthcare needs of your household?

55. (Check All That Apply)*

    1. Primary healthcare
    2. Pediatric (child) care
    3. Prenatal (pregnancy) care
    4. Dental care
    5. Healthcare education/prevention
    6. Nutrition and exercise programs
    7. Services to help alleviate stress/anxiety/depression
    8. Assistance with daily living for elderly/disabled residents

    1. Health screening services
    2. Substance abuse treatment
    3. Smoking cessation programs
    4. Drinking cessation programs
    5. Transportation to healthcare services
    6. Don't know
    7. None
    8. Other
57. If "Other" Please Specify:

59. 10. Which of the following community assets do you currently use, and which do you think are most needed in your community?

61. Parks & Recreational Spaces

    1. Currently Use
    2. Needed in Community
62. Public Libraries

    1. Currently Use
    2. Needed in Community
63. Community Centers

    1. Currently Use
    2. Needed in Community
64. Local Businesses & Markets

    1. Currently Use
    2. Needed in Community
66. Civic Organizations

    1. Currently Use
    2. Needed in Community
67. Religious or Spiritual Institutions

    1. Currently Use
    2. Needed in Community
68. Health & Wellness Services

    1. Currently Use
    2. Needed in Community
69. Educational Programs & Resources

    1. Currently Use
    2. Need in Community
71. Public Transportation

    1. Currently Use
    2. Needed in Community
72. Social Services & Support Organizations

    1. Currently Used
    2. Needed in Community
73. Job Training & Employment Services

    1. Currently Use
    2. Needed in Community
74. Senior Services & Supports

    1. Currently Use
    2. Needed in Community
76. Food Assistance Programs (food banks, community gardens, etc.)

    1. Currently Use
    2. Needed in Community
77. Technology Access (public WiFi, computer labs)

    1. Currently Use
    2. Needed in Community
78. Reentry Services

    1. Currently Use
    2. Needed in Community
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