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* 1. Mark all services your household got from our agency within the last 12 months:

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* 2. I got the information and services I needed:

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* 3. Additional program/service I would like Community Action to offer:

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* 4. I had a positive experience when receiving services:

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* 5. I was informed about other agency or community services:

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* 6. Are there any problems or needs you or your family faced within the last 12 months you were unable to get help with?

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* 7. What are the greatest challenges your household is currently facing? (Check all that apply)

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* 8. What is one suggestion you have for Community Action to improve on?

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* 9. How has Community Action made a difference in your life?

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* 10. Date

Date

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* 11. What county do you live in?

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* 12. Optional: Would you be willing to share your story?

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* 13. Optional: If you're willing to share your story, please provide your contact information.

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* 14. Optional: Other Comments

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