The Nez Perce Tribe Mamáy’asnim Hitéemenweese Program

Community Needs Assessment Survey

Community assessments help Head Start programs remain responsive to the needs of the children and families they serve. They provide a starting point for understanding community strengths and identifying gaps in services. Community assessments also help mobilize necessary resources. When used in conjunction with other program data, they inform program planning. Your name will be entered into a drawing if you provide your name, phone number and/or email at the end of survey. Qe’ciyew’yew’

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* 1. What category best describes you?

Parent working in the home

Parent working outside the home

Foster Parent

Parent in school (College /V0-Tech)

Grandparent/Guardian

Teen parent in school

Teen parent working

Other (please specify)

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* 2. Your gender/sex:

Male

Female

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* 3. Your age:

15 and under

16-21

22-27

28-33

34-39

40-45

46-51

52-58

Over 60

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* 4. Your ethnicity/race:

White

African-American

Asian/Pacific Islander

Hispanic

Native American/Alaskan (Enrolled)

Nez Perce /or other tribe descendant

Tribal Affiliation

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* 5. What is the primary language spoken in your home?

English

Ni-Mii-puu-timpt

Other Tribal Languages

Spanish

Other (please specify)

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* 6. Are you or your spouse a Head Start graduate?

Yes Yourself

Yes Spouse/Partner

No Yourself

No Spouse/Partner

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* 7. What is your marital status?

Single

Married

Divorced

Separated

Living with my partner

Widowed

Other (please specify)

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* 8. Which of the following best describes your family? (Check only one)

Two Parent Family

Single Mother

Single Father

Multi-Generational Family

Foster Parent

Shared Custody

Grandparents Raising Grandchildren

Other (please specify)

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* 9. Including yourself, How many live in your household?

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* 10. Do you currently have children in:

Head Start

Early Head Start

No Children in this age group

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* 11. How many children live with you? (under 18 years old)

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* 12. How old is each child?

	Child #1	Child #2	Child #3	Child #4	Child #5
0 to 2 years old	0 to 2 years old Child #1	0 to 2 years old Child #2	0 to 2 years old Child #3	0 to 2 years old Child #4	0 to 2 years old Child #5
3 to 5 years old	3 to 5 years old Child #1	3 to 5 years old Child #2	3 to 5 years old Child #3	3 to 5 years old Child #4	3 to 5 years old Child #5
6 to 13 years old	6 to 13 years old Child #1	6 to 13 years old Child #2	6 to 13 years old Child #3	6 to 13 years old Child #4	6 to 13 years old Child #5
14 to 17 years old	14 to 17 years old Child #1	14 to 17 years old Child #2	14 to 17 years old Child #3	14 to 17 years old Child #4	14 to 17 years old Child #5

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* 13. List the community that you live in

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* 14. About your home, does your family:

Rent

Own

Buying home

Other (please specify)

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* 15. About your living situation, does your family live:

Alone as a family

With relatives

With friends

In a shelter

Homeless

Hotel/Motel

Other (please specify)

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* 16. How often are these statements true about your housing?

	Never True	Sometimes True	Often True	Always True
Our housing is…	Our housing is… Never True	Our housing is… Sometimes True	Our housing is… Often True	Our housing is… Always True
Just the right size	Just the right size Never True	Just the right size Sometimes True	Just the right size Often True	Just the right size Always True
Crowded	Crowded Never True	Crowded Sometimes True	Crowded Often True	Crowded Always True
Needs major repairs	Needs major repairs Never True	Needs major repairs Sometimes True	Needs major repairs Often True	Needs major repairs Always True
Kept in good condition	Kept in good condition Never True	Kept in good condition Sometimes True	Kept in good condition Often True	Kept in good condition Always True

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* 17. What type of health insurance do you have?

None

Medicaid

Private /Provided through work

Medicaid/Chip

Other (please specify)

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* 18. Who does your health insurance plan cover? Check all that apply.

Self

Spose

Children

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* 19. If you have private insurance, who pays the premium, cost?

My employer pays majority of the cost

I (or my family) pays majority of the cost

Employer and I (or my family) each pay about half

Other (please specify)

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* 20. Who does your health insurance plan cover? Check all that apply.

Self

Spouse

Children

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* 21. Are your children covered with this same insurance, another type of insurance, or not covered at all?

Same insurance

Different insurance

Not insured

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* 22. If you don’t have insurance, are you eligible for Medicaid?

Yes

Don’t know

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* 23. What are the main reasons why your child(ren) do not have insurance?

Don’t know how or where to get it

Job doesn’t provide it

Don’t need it

Can’t afford it

Don’t qualify for it

Other (please specify)

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* 24. Where do you usually take your child to get medical care? (Check all that apply)

Family doctor

Community health clinic

Emergency room

Family dentist

Nimiipuu Health /Indian Health Clinics

Other (please specify)

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* 25. How many times have you and your family needed health care in the last year?

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* 26. Do you have dental insurance?

Yes

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* 27. What type of dental insurance do you have?

None

Medicaid

Provided through work Other

Other (please specify)

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* 28. Are your children covered with this same dental insurance, another type of insurance, or not covered at all?

Same insurance

Different insurance

Not insured

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* 29. Do your children regularly visit a dentist?

Yes

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* 30. How does your child get to Head Start?

Car

Public Transportation

Taxi

Carpool

Head Start transportation

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* 31. Do you have a reliable vehicle?

Yes, but is not reliable

Yes, vehicle is reliable

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* 32. Are you currently employed? ( Mark one each for mother and father)

	Mother of child	Father of child
Not employed	Not employed Mother of child	Not employed Father of child
Employed full-time	Employed full-time Mother of child	Employed full-time Father of child
Employed, part-time	Employed, part-time Mother of child	Employed, part-time Father of child
On-call	On-call Mother of child	On-call Father of child
Stay at home parent	Stay at home parent Mother of child	Stay at home parent Father of child
unable to work, Disabled	unable to work, Disabled Mother of child	unable to work, Disabled Father of child
Retired not working	Retired not working Mother of child	Retired not working Father of child
Seasonal	Seasonal Mother of child	Seasonal Father of child
Student	Student Mother of child	Student Father of child

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* 33. What keeps you from working as much as you want to or need to?

Lack of child care

No transportation

Skills don’t fit jobs

Fears of losing public assistance

Discrimination

In School

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* 34. Do you need child care for your children on a regular basis?

Yes

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* 35. What type(s) of child care are you currently using?

Older siblings

Relatives

Babysitter in the home

Licensed Family Child Care

Licensed Child Care Center

Boys and Girls Club

Friends

Have to leave child alone

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* 36. What was the main factor that influenced your decision about the child care arrangement you currently have?

Cost was affordable

Location near home or work

My child would be safe Program has accreditation

Got a referral from family or friend

None of the above

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* 37. About how many hours per week is your child(ren) in child care?

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* 38. What types of child care have you needed in the last 12 months?

Full-day care

Half-day care

Before/after school care

Night or weekend care

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* 39. Please check the periods that you most need child care during the week? (Check only one)

Mornings only

Evenings only

Weekends

Afternoons only

Highly varying hours and days

Regular work day/week (i.e. m-f 8-4:30)

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* 40. How difficult is it for you to arrange back-up child care when your regular child care arrangement doesn’t’ work?

Very difficult

Some what difficult

Not at all difficult

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* 41. How difficult is it for you to find child care for your children in the summer months when Head Start or school is not in session?

Very difficult

Some what difficult

Not at all difficult

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* 42. What is your annual household income?

Less than $12,760

$12,760 - $24,999

$25,000 - $34,999

$35,000 - $44,999

$45,000 - $54,999

Over $60,000

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* 43. Are you supposed to get child support or alimony?

Yes, child support

Yes, alimony

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* 44. Do you get your child support or alimony?

Yes, but rarely

Yes, sometimes

Yes, most of the time

Yes, always

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* 45. If so, what type of services or financial assistance do you receive?

Medicaid/ Chip

TANF

Social Security

Food Stamps

Tribal benefits

SSI

Section 8 Housing

Workers Compensation

Unemployment Benefits

Medicare

Free and Reduced hot lunch

Tribal Housing

Commodity Foods

Tribal Assistance

Financial assistance from community agency

Idaho North central Health District

Other (please specify)

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* 46. Do you ever use local food banks or food pantries?

Yes

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* 47. If yes, about how often?

Less than once a month

M0re than once a month

About once a month

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* 48. Indicate the highest level of education completed by: ( Mark one for you and your spouse/partner)

	Jr, High school	Some high school	High School graduate	Vocational/ Trade school	Some College	AA degree (2 year degree)	Bachelor’s degree	Some graduate school	Master’s Degree
Yourself	Yourself Jr, High school	Yourself Some high school	Yourself High School graduate	Yourself Vocational/ Trade school	Yourself Some College	Yourself AA degree (2 year degree)	Yourself Bachelor’s degree	Yourself Some graduate school	Yourself Master’s Degree
Spouse/Partner	Spouse/Partner Jr, High school	Spouse/Partner Some high school	Spouse/Partner High School graduate	Spouse/Partner Vocational/ Trade school	Spouse/Partner Some College	Spouse/Partner AA degree (2 year degree)	Spouse/Partner Bachelor’s degree	Spouse/Partner Some graduate school	Spouse/Partner Master’s Degree

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* 49. Are you or your spouse/partner currently in school? ( Mark one for you and your spouse/partner)

	No	Yes,	full-time Yes,	part-time Other
Yourself	Yourself No	Yourself Yes,	Yourself full-time Yes,	Yourself part-time Other
Spouse/Partner	Spouse/Partner No	Spouse/Partner Yes,	Spouse/Partner full-time Yes,	Spouse/Partner part-time Other

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* 50. If you or your spouse/partner are in school, what type of school? ( Mark one for you and your spouse/partner)

	Working on GED	Vocational School	College Other
Yourself	Yourself Working on GED	Yourself Vocational School	Yourself College Other
Spouse/Partner	Spouse/Partner Working on GED	Spouse/Partner Vocational School	Spouse/Partner College Other

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* 51. If you are not in school, do you or your spouse/partner want to attend school in the future?

	No	Yes
Yourself	Yourself No	Yourself Yes
Spouse/Partner	Spouse/Partner No	Spouse/Partner Yes

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* 52. What do you consider to be barriers that prevent families from getting needed services? (Check only those that apply to you and your family)

Not aware of existing services

Services are too far away from home

Waiting list are too long

Agencies not open at convenient time

Child care is not available

Transportation

Agency fees are too high

Rules & eligibility exclude people

Agency staff are rude

Concerns about confidentiality

Uncomfortable with “outsiders”

None

Other (please specify)

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* 53. Indicate if your family has any of the following needs:

Education

Employment services

Food and nutrition help

Health-related or medical help

Budgeting or stretching income

Housing improvements

Resources in community

Emergency rent, utility or shelter help

Transportation

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* 54. Who or where do you turn for assistance most often?

Church

Health clinic

Friend

Teacher

Family member

Co-worker

Child care center

Social services

Other (please specify)

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* 55. Please indicate how adequate the following services are in your community:

	Don’t Know	Not Available	Poor	Good	Excellent
Child care	Child care Don’t Know	Child care Not Available	Child care Poor	Child care Good	Child care Excellent
Community & church organizations	Community & church organizations Don’t Know	Community & church organizations Not Available	Community & church organizations Poor	Community & church organizations Good	Community & church organizations Excellent
Crisis intervention & counseling	Crisis intervention & counseling Don’t Know	Crisis intervention & counseling Not Available	Crisis intervention & counseling Poor	Crisis intervention & counseling Good	Crisis intervention & counseling Excellent
Education, literacy & mentoring	Education, literacy & mentoring Don’t Know	Education, literacy & mentoring Not Available	Education, literacy & mentoring Poor	Education, literacy & mentoring Good	Education, literacy & mentoring Excellent
Employment &training	Employment &training Don’t Know	Employment &training Not Available	Employment &training Poor	Employment &training Good	Employment &training Excellent
Mental health services	Mental health services Don’t Know	Mental health services Not Available	Mental health services Poor	Mental health services Good	Mental health services Excellent
Information & referral	Information & referral Don’t Know	Information & referral Not Available	Information & referral Poor	Information & referral Good	Information & referral Excellent
Substance abuse treatment	Substance abuse treatment Don’t Know	Substance abuse treatment Not Available	Substance abuse treatment Poor	Substance abuse treatment Good	Substance abuse treatment Excellent
Emergency assistance (food, etc)	Emergency assistance (food, etc) Don’t Know	Emergency assistance (food, etc) Not Available	Emergency assistance (food, etc) Poor	Emergency assistance (food, etc) Good	Emergency assistance (food, etc) Excellent
Child welfare & foster care	Child welfare & foster care Don’t Know	Child welfare & foster care Not Available	Child welfare & foster care Poor	Child welfare & foster care Good	Child welfare & foster care Excellent
Law enforcement	Law enforcement Don’t Know	Law enforcement Not Available	Law enforcement Poor	Law enforcement Good	Law enforcement Excellent
Culture & art	Culture & art Don’t Know	Culture & art Not Available	Culture & art Poor	Culture & art Good	Culture & art Excellent
Transportation	Transportation Don’t Know	Transportation Not Available	Transportation Poor	Transportation Good	Transportation Excellent
Family support services	Family support services Don’t Know	Family support services Not Available	Family support services Poor	Family support services Good	Family support services Excellent
Public health services (IHS)	Public health services (IHS) Don’t Know	Public health services (IHS) Not Available	Public health services (IHS) Poor	Public health services (IHS) Good	Public health services (IHS) Excellent
Legal aid	Legal aid Don’t Know	Legal aid Not Available	Legal aid Poor	Legal aid Good	Legal aid Excellent
Recreation	Recreation Don’t Know	Recreation Not Available	Recreation Poor	Recreation Good	Recreation Excellent
Youth -Boys and Girls Club	Youth -Boys and Girls Club Don’t Know	Youth -Boys and Girls Club Not Available	Youth -Boys and Girls Club Poor	Youth -Boys and Girls Club Good	Youth -Boys and Girls Club Excellent

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* 56. How did you hear about Head Start?

Friends/relatives

Doctor’s office

DHS office

Head Start staff

Head Start flyer or brochure

School

Social Media

Newspaper

Tribal Radio Station

Other (please specify)

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* 57. Have you volunteered in the Head Start Program?

Yes

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* 58. If you have volunteered please check all of the ways?

Helping in the classroom

Serving on Center Parent Committee

Helping with field trips

Working on agency committees

Helping on the bus

Helping with cooking

Serving on Policy Council

Translating, verbal or written

Special Projects

Other (please specify)

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* 59. If yes, how would you rate your experience?

Very good

Good

Needs Improvement

Unacceptable

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* 60. If no, why haven’t you volunteered?

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* 61. To help us plan for the future would you please tell us what program would best fit your needs?

Home based program with 1 home visit a week

Full day–full year program; five days a week; year round

Full day program; five days per week; 9 months a year

Part day program; four days a week;

3 ½ hours a day Early Head Start (Infants and Toddlers)

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* 62. What program option would best meet your family’s needs?

The current schedule is fine

A 6 hour full day program available during the school year M-Th

A 3.5 hour part time day program available during the school year -M-Th

A 6 hour full day program available year round- M-Th

A 3.5 hour part day program available year round - M-TH

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* 63. Please rate your experience in Head Start.

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* 64. What areas of the Head Start program do you feel could use improvement? (Check all that apply)

Education/Literacy

Health Assessment/Follow-up

Nutrition & Meal Service

Disabilities Assessment/Follow-up

Transportation

Family/Community Partnerships

Classroom environment

Mental Health

Curriculum

incorporate tribal language and culture

Facilities repair

New Facilities

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* 65. Family needs (check all that apply)

Learning Nez Perce Language

Parenting/Child Development

Finding a job

Finding a better paying job

Affordable housing

Money to repair substandard housing

Budgeting

Quitting the use of alcohol

Quitting the use of tobacco

Quitting the use of illegal drugs

Quitting the use of prescription drugs

Becoming a US citizen

How to talk to your teen

Services for disabled child in your home

Services for senior adult in your home

Services for disabled adult in your home

Finding better transportation

Getting more food in home

Getting child support from absent parent

Finding legal assistance

Unsafe neighborhoods

Victim of domestic violence

Quit Gambling

Other (please specify)

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* 66. What prevents you or your family from using a service or program in the community?

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* 67. If applicable, what prevents you or your family from using a Nez Perce Tribal service or program?

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* 68. Does your community have a problem with any of these issues?

	No Problem	Somewhat of a Problem	Major Problem	I don't know
Loss of Nez Perce Culture/Language	Loss of Nez Perce Culture/Language No Problem	Loss of Nez Perce Culture/Language Somewhat of a Problem	Loss of Nez Perce Culture/Language Major Problem	Loss of Nez Perce Culture/Language I don't know
Education & vocational training for adults	Education & vocational training for adults No Problem	Education & vocational training for adults Somewhat of a Problem	Education & vocational training for adults Major Problem	Education & vocational training for adults I don't know
Job opportunities	Job opportunities No Problem	Job opportunities Somewhat of a Problem	Job opportunities Major Problem	Job opportunities I don't know
Public transportation	Public transportation No Problem	Public transportation Somewhat of a Problem	Public transportation Major Problem	Public transportation I don't know
Affordable housing	Affordable housing No Problem	Affordable housing Somewhat of a Problem	Affordable housing Major Problem	Affordable housing I don't know
Social services	Social services No Problem	Social services Somewhat of a Problem	Social services Major Problem	Social services I don't know
Legal services	Legal services No Problem	Legal services Somewhat of a Problem	Legal services Major Problem	Legal services I don't know
Water supply and quality	Water supply and quality No Problem	Water supply and quality Somewhat of a Problem	Water supply and quality Major Problem	Water supply and quality I don't know
Air quality	Air quality No Problem	Air quality Somewhat of a Problem	Air quality Major Problem	Air quality I don't know
Injuries (car crashes, work-related, in the home)	Injuries (car crashes, work-related, in the home) No Problem	Injuries (car crashes, work-related, in the home) Somewhat of a Problem	Injuries (car crashes, work-related, in the home) Major Problem	Injuries (car crashes, work-related, in the home) I don't know
Community/Recreation facilities	Community/Recreation facilities No Problem	Community/Recreation facilities Somewhat of a Problem	Community/Recreation facilities Major Problem	Community/Recreation facilities I don't know
Spouse or significant other abuse	Spouse or significant other abuse No Problem	Spouse or significant other abuse Somewhat of a Problem	Spouse or significant other abuse Major Problem	Spouse or significant other abuse I don't know
Elder abuse or neglect	Elder abuse or neglect No Problem	Elder abuse or neglect Somewhat of a Problem	Elder abuse or neglect Major Problem	Elder abuse or neglect I don't know
Youth violence	Youth violence No Problem	Youth violence Somewhat of a Problem	Youth violence Major Problem	Youth violence I don't know
Sexual assault/rape	Sexual assault/rape No Problem	Sexual assault/rape Somewhat of a Problem	Sexual assault/rape Major Problem	Sexual assault/rape I don't know
Depression	Depression No Problem	Depression Somewhat of a Problem	Depression Major Problem	Depression I don't know
Suicide	Suicide No Problem	Suicide Somewhat of a Problem	Suicide Major Problem	Suicide I don't know

Other (please specify)

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* 69. Do people in your community have a problem finding or using these services?

	No Problem	Somewhat of a Problem	Major Problem	I don’t know
Medical care	Medical care No Problem	Medical care Somewhat of a Problem	Medical care Major Problem	Medical care I don’t know
Hospital services	Hospital services No Problem	Hospital services Somewhat of a Problem	Hospital services Major Problem	Hospital services I don’t know
Dental care	Dental care No Problem	Dental care Somewhat of a Problem	Dental care Major Problem	Dental care I don’t know
Mental Health care/counseling	Mental Health care/counseling No Problem	Mental Health care/counseling Somewhat of a Problem	Mental Health care/counseling Major Problem	Mental Health care/counseling I don’t know
Emergency medical care	Emergency medical care No Problem	Emergency medical care Somewhat of a Problem	Emergency medical care Major Problem	Emergency medical care I don’t know
Drug & alcohol treatment	Drug & alcohol treatment No Problem	Drug & alcohol treatment Somewhat of a Problem	Drug & alcohol treatment Major Problem	Drug & alcohol treatment I don’t know
Health education programs	Health education programs No Problem	Health education programs Somewhat of a Problem	Health education programs Major Problem	Health education programs I don’t know
Transportation to health care	Transportation to health care No Problem	Transportation to health care Somewhat of a Problem	Transportation to health care Major Problem	Transportation to health care I don’t know
Private health insurance medical coverage	Private health insurance medical coverage No Problem	Private health insurance medical coverage Somewhat of a Problem	Private health insurance medical coverage Major Problem	Private health insurance medical coverage I don’t know
Enrolling in Medicaid/Medicare	Enrolling in Medicaid/Medicare No Problem	Enrolling in Medicaid/Medicare Somewhat of a Problem	Enrolling in Medicaid/Medicare Major Problem	Enrolling in Medicaid/Medicare I don’t know
Food assistance ($ or food)	Food assistance ($ or food) No Problem	Food assistance ($ or food) Somewhat of a Problem	Food assistance ($ or food) Major Problem	Food assistance ($ or food) I don’t know
Social Services	Social Services No Problem	Social Services Somewhat of a Problem	Social Services Major Problem	Social Services I don’t know
Community/recreation facilities	Community/recreation facilities No Problem	Community/recreation facilities Somewhat of a Problem	Community/recreation facilities Major Problem	Community/recreation facilities I don’t know
Housing assistance (public housing or aid)	Housing assistance (public housing or aid) No Problem	Housing assistance (public housing or aid) Somewhat of a Problem	Housing assistance (public housing or aid) Major Problem	Housing assistance (public housing or aid) I don’t know
Utilities assistance (to pay electricity or fuel bill)	Utilities assistance (to pay electricity or fuel bill) No Problem	Utilities assistance (to pay electricity or fuel bill) Somewhat of a Problem	Utilities assistance (to pay electricity or fuel bill) Major Problem	Utilities assistance (to pay electricity or fuel bill) I don’t know

Other (please specify)

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* 70. Do people in your community have a problem finding or using these services?

	No Problem	Somewhat of a Problem	Major Problem	I don’t know
Care for pregnant women	Care for pregnant women No Problem	Care for pregnant women Somewhat of a Problem	Care for pregnant women Major Problem	Care for pregnant women I don’t know
Child health care	Child health care No Problem	Child health care Somewhat of a Problem	Child health care Major Problem	Child health care I don’t know
Childhood immunizations	Childhood immunizations No Problem	Childhood immunizations Somewhat of a Problem	Childhood immunizations Major Problem	Childhood immunizations I don’t know
Child care for infants/preschoolers	Child care for infants/preschoolers No Problem	Child care for infants/preschoolers Somewhat of a Problem	Child care for infants/preschoolers Major Problem	Child care for infants/preschoolers I don’t know
After school care	After school care No Problem	After school care Somewhat of a Problem	After school care Major Problem	After school care I don’t know
Poverty in families with children	Poverty in families with children No Problem	Poverty in families with children Somewhat of a Problem	Poverty in families with children Major Problem	Poverty in families with children I don’t know
Child abuse/neglect	Child abuse/neglect No Problem	Child abuse/neglect Somewhat of a Problem	Child abuse/neglect Major Problem	Child abuse/neglect I don’t know

Other (please specify)

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* 71. Are these unhealthy behaviors a problem in your community?

	No problem	Somewhat of a Problem	Major Problem	I don't know
Alcohol Abuse	Alcohol Abuse No problem	Alcohol Abuse Somewhat of a Problem	Alcohol Abuse Major Problem	Alcohol Abuse I don't know
Illegal drug use/substance abuse	Illegal drug use/substance abuse No problem	Illegal drug use/substance abuse Somewhat of a Problem	Illegal drug use/substance abuse Major Problem	Illegal drug use/substance abuse I don't know
Cigarette smoking among adults	Cigarette smoking among adults No problem	Cigarette smoking among adults Somewhat of a Problem	Cigarette smoking among adults Major Problem	Cigarette smoking among adults I don't know
Cigarette smoking among people under 18	Cigarette smoking among people under 18 No problem	Cigarette smoking among people under 18 Somewhat of a Problem	Cigarette smoking among people under 18 Major Problem	Cigarette smoking among people under 18 I don't know
Driving and drinking	Driving and drinking No problem	Driving and drinking Somewhat of a Problem	Driving and drinking Major Problem	Driving and drinking I don't know
Driving or riding in a car without seatbelts	Driving or riding in a car without seatbelts No problem	Driving or riding in a car without seatbelts Somewhat of a Problem	Driving or riding in a car without seatbelts Major Problem	Driving or riding in a car without seatbelts I don't know
Sexually transmitted disease	Sexually transmitted disease No problem	Sexually transmitted disease Somewhat of a Problem	Sexually transmitted disease Major Problem	Sexually transmitted disease I don't know
Lack of physical activity or exercise	Lack of physical activity or exercise No problem	Lack of physical activity or exercise Somewhat of a Problem	Lack of physical activity or exercise Major Problem	Lack of physical activity or exercise I don't know
Poor eating habits/lack of good nutrition	Poor eating habits/lack of good nutrition No problem	Poor eating habits/lack of good nutrition Somewhat of a Problem	Poor eating habits/lack of good nutrition Major Problem	Poor eating habits/lack of good nutrition I don't know
Gambling	Gambling No problem	Gambling Somewhat of a Problem	Gambling Major Problem	Gambling I don't know

Other (please specify)

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* 72. Do people in your community have a problem with any of these diseases or disabilities?

	No Problem	Somewhat of a Problem	Major Problem	I don’t know
Cancer	Cancer No Problem	Cancer Somewhat of a Problem	Cancer Major Problem	Cancer I don’t know
Obesity	Obesity No Problem	Obesity Somewhat of a Problem	Obesity Major Problem	Obesity I don’t know
Diabetes	Diabetes No Problem	Diabetes Somewhat of a Problem	Diabetes Major Problem	Diabetes I don’t know
Heart Disease	Heart Disease No Problem	Heart Disease Somewhat of a Problem	Heart Disease Major Problem	Heart Disease I don’t know
High blood pressure	High blood pressure No Problem	High blood pressure Somewhat of a Problem	High blood pressure Major Problem	High blood pressure I don’t know
HIV/AIDS	HIV/AIDS No Problem	HIV/AIDS Somewhat of a Problem	HIV/AIDS Major Problem	HIV/AIDS I don’t know
Stroke	Stroke No Problem	Stroke Somewhat of a Problem	Stroke Major Problem	Stroke I don’t know
Mental health problems	Mental health problems No Problem	Mental health problems Somewhat of a Problem	Mental health problems Major Problem	Mental health problems I don’t know
Dental health problems	Dental health problems No Problem	Dental health problems Somewhat of a Problem	Dental health problems Major Problem	Dental health problems I don’t know
Learning and developmental disabilities	Learning and developmental disabilities No Problem	Learning and developmental disabilities Somewhat of a Problem	Learning and developmental disabilities Major Problem	Learning and developmental disabilities I don’t know

Other (please specify)

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* 73. Address

Name

Email Address

Phone Number

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* 74. Address

Name

Email Address

Phone Number