NEK-CAP, Inc. 2020 Community Needs Assessment

Thank you for participating in our survey. Please answer every question. This information will assist us in helping people and meeting community needs. Your identity and answers will be confidential and anonymous and we are not asking for your name. Please answer the following questions by putting a check mark in the box next to the most accurate answer.

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* 1. Today's Date

Date

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* 2. Which describes you and your relationship to NEK-CAP, Inc.
(Check all that apply):

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* 3. County of Residence:

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* 4. Are you:

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* 5. What is your age?

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* 6. How far did you go in school?

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* 7. What is your Race or Ethnic Heritage?

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* 8. What language do you speak at home?

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* 9. What is your marital status?

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* 10. Do you have minor children? (under 18) 

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* 11. Are you the child(ren)'s primary caretaker? 

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* 12. If you have children or other dependents under your your care: What is your family situation?

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* 13. Who provides your childcare? (or dependent care)? (check all that apply)

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* 14. Is your child care (dependent care) provider dependable?

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* 15. Do you need different child care (dependent care) help?

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* 16. What kind of child care (dependent care) help do you need?

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* 17. Have you ever lost  job because you didn't have dependable child or dependent care?

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* 18. Are you caring for adult children or adult dependents including seniors (Due to mental or physical disability)?

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* 19. Who provides care for the adult children or adult dependents (check all that apply)?

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* 20. How many people live where you stay?

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* 21. List any agencies in your community that you may receive help from: for example - food pantry; meals on wheels; clothing; health; mental health, etc

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* 22. Are you able to work?

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* 23. What is your work status?

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* 24. If Unemployed, are you currently looking for work?

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* 25. If you are unemployed, please select the reason(s) why below:

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* 26. Would you like help with these job related activities (check all that apply):

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* 27. Do you have reliable telephone access?

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* 28. Do you have access to the internet?

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* 29. Where do you usually use the internet

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* 30. What is your zip code?

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* 31. What is your housing status

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* 32. Carefully read questions 32 to 49 and choose the one that applies to you and your family - You will answer all of them - Choosing YES for the one that fits your family or you as an individual. This refers to your GROSS income.
Are you a family of one with an income of $12,760 or LESS annually?

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* 33. Are you a family of one with an income of $12,760 or MORE annually?

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* 34. Are you a family of two with an income of $17,240 or LESS annually?

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* 35. Are you a family of two with an income of $17,240 or MORE annually?

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* 36. Are you a family of three with an income of $21,720 or LESS annually?

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* 37. Are you a family of three with an income of $21,720 or MORE annually?

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* 38. Are you a family of four with an income of $26,200 or LESS annually?

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* 39. Are you a family of four with an income of $26,200 or MORE annually?

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* 40. Are you a family of five with an income of $30,680 or LESS annually?

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* 41. Are you a family of five with an income of $30,680 or MORE annually?

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* 42. Are you a family of six with an income of $35,160 or LESS annually?

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* 43. Are you a family of six with an income of $35,160 or MORE annually?

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* 44. Are you a family of seven with an income of $39,640 or LESS annually?

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* 45. Are you a family of seven with an income of $39,640 or MORE annually?

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* 46. Are you a family of eight with an income of $44,120 or LESS annually?

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* 47. Are you a family of eight with an income of $44,120 or MORE annually?

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* 48. If you have more than eight in your family,  please give an approximate gross annual income.

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* 49. Which of these monthly bills do you have? Check all that apply

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* 50. What types of income do you have? Check all that apply

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* 51. Do you or any household member receive any of these types of assistance? (Check all that apply)

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* 52. Do You, or someone in your home have special needs?

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* 53. Do you have any of these School/Education related needs? (check all that apply)

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* 54. In the past 24 months, has your child had to transfer schools because you moved?

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* 55. Do you have any of the following housing related needs? (Check all that apply)

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* 56. Do you need any of the following transportation related help (check all that apply)?

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* 57. Have you ever lost a job (or not be able to accept a job offer) because of transportation issues

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* 58. Are you in need of help with any of these things: (Check all that apply)

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* 59. Are you in need of help with any of these things: (Check all that apply)

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* 60. Where do you usually get your food/groceries?

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* 61. How many miles do you have to drive to get your food/groceries?

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* 62. Do you need information on how to cook for any of these special diets? Check all that apply

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* 63. Do you need information on food nutrition?

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* 64. Do you need to know how to store food so it will last longer?

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* 65. Do you or someone in your household have any of these health care needs? (Check all that apply)

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* 66. Do you have health insurance or other health care coverage

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* 67. Are there others in your household who are uninsured?

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* 68. If you have health insurance, who provides your health insurance?

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* 69. Do you have any of these financial need or problems? (Check all that apply)

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* 70. Are you a US Veteran?

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* 71. If you are a US Veteran, are you receiving Veteran's benefits?

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* 72. If you are not receiving Veteran's benefits, do you need help getting them?

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* 73. If you are a Veteran or dependent, do you need assistance with any of the following? (Check all that apply)

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* 74. Anything else you would like to add , that you feel is important?

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* 75. If you would like to leave your contact information for any follow up or if you would like to participate in any of our upcoming county focus meetings - thank you for you participation in this survey.

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