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Please answer the following questions by selecting what you feel is the most accurate answer.

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* 1. Lack of Affordable Housing in this community is a problem because...(choose one)

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* 2. Unemployment is a problem in this community because... (choose one)

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* 3. High heating and utility costs are a problem in this community because... (choose one)

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* 4. In your view of the following, which are most important to having a good community? (Choose 3)

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* 5. Transportation is a problem because... (choose all that apply)

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* 6. Please choose three (3) of the following areas that are most important to you right now:

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* 7. Do all members of your household currently have health insurance?

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* 8. If no, which members of your household are uninsured?

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* 9. Are you concerned about: (choose all that apply)

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* 10. Which of the following are missing from your neighborhood? (choose all that apply)

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* 11. We would like to know some general information about you that will help us use the results of this survey. Your identity and answers are confidential and we are not asking for your name. 

Culture/Ethnicity (choose all that apply)

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* 12. Gender: How do you identify?

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* 13. Age range: (choose one)

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* 14. Marital Status: (choose one)

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* 15. Education (last grade completed):

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* 16. Have you received a:

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* 17. Town of Residence:

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* 18. Source of Income: (If you have more than one source of income, choose all that apply)

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* 19. Gross Household Income Per Month (Before taxes are taken out)

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* 20. Are you a:

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* 21. How much is your monthly rent or mortgage payment?

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* 22. Is your monthly rent/ mortgage payment subsidized?

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* 23. How many times have you moved in the past year?

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* 24. Do you receive SNAP (food stamps) benefits?

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* 25. Do you believe you have adequate access to get food supplies for your household?

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* 26. If no, have you accessed a food pantry in the past 12 months?

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* 27. In general, do you feel that you are:

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* 28. Is there something you want to do or are determined to do within the next few years?

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* 29. If yes, please share your goals:

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* 30. Are you currently receiving or have received services from TEAM in the last year?

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