Household Needs Survey 2024

Dear Community Member,

Please take 10 minutes to complete the following confidential survey to help us understand your household needs. We value your input and will keep your responses private and confidential.

We are asking residents of Marquette, Outagamie, Portage, Waupaca, and Waushara counties to complete this survey to help us understand local needs and plan future programs. Please only complete one survey per household.

You must have income at or below 200% of the Federal Poverty Level and live in CAP’s service area to participate. (See table below.) If you want to enter for a chance to win a $20 Kwik Trip gift card, please complete the entry form at the end of the survey. We will randomly select 5 people from each county who return the survey by December 1, 2024 to receive one gift card each.

CAP Services is a local nonprofit established in Central Wisconsin in 1966. We provide services for housing and transportation, job skills, business coaching and lending, child and family development, multicultural services, and more.

For information about CAP programs or for help completing this survey, call 1-844-314-8004. You can also request a paper copy of the survey if preferred. Learn more about the survey at www.capservices.org/CNA. The surveys are available in English, Spanish, and Hmong.

Sincerely, 

Nicole Harrison, CAP Services’ President & CEO

Your household income must be at or below 200% Federal Poverty Level to participate. (Use the table to estimate or call CAP at 1-844-314-8004 if you need help answering this question.)

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* 1. What county do you live in?

Marquette County

Outagamie County

Portage County

Waupaca County

Waushara County

None of the above

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* 2. What is your ZIP code?

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* 3. How many people live in your household?

Adults (18 and older)

Children (under 18)

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* 4. How many of the children who live in your household are age 5 or younger?

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* 5. What is your estimated annual household income including all sources of income (e.g. employment, unemployment, social security, children support, etc.)?

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* 6. What is your age?

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* 7. What is your gender?

Male

Female

Non-binary

Prefer to self-describe (please specify)

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* 8. What is your ethnicity?

Hispanic, Latino, or Spanish Origins

Not Hispanic, Latino, or Spanish Origins

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* 9. What is your race?

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Multi-Race (two or more of above)

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* 10. Does anyone in your household have a disability?

Yes

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* 11. Is one or more adults in your household currently:

	Yes	No
a. employed?	a. employed? Yes	a. employed? No
b. retired?	b. retired? Yes	b. retired? No
c. unable to work due to a disability?	c. unable to work due to a disability? Yes	c. unable to work due to a disability? No
d. unemployed and seeking work?	d. unemployed and seeking work? Yes	d. unemployed and seeking work? No
e. a stay-at-home parent?	e. a stay-at-home parent? Yes	e. a stay-at-home parent? No

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* 12. Please check the box that best describes your housing situation.

Rent

Own a home

Homeless (unsheltered)

Other (please specify)

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* 13. Now we are going to ask you a few questions about your experience over the past year. Please select the response on the table that best describes how often you experienced the situation.

	Never	Seldom, 1-3 times this past year	Sometimes, 4-5 times this past year	Often, every other month this past year or similar	Almost always, almost every month this past year
In the past 12 months, have you been worried about losing your housing?	In the past 12 months, have you been worried about losing your housing? Never	In the past 12 months, have you been worried about losing your housing? Seldom, 1-3 times this past year	In the past 12 months, have you been worried about losing your housing? Sometimes, 4-5 times this past year	In the past 12 months, have you been worried about losing your housing? Often, every other month this past year or similar	In the past 12 months, have you been worried about losing your housing? Almost always, almost every month this past year
In the past 12 months, have you been worried about feeding your household?	In the past 12 months, have you been worried about feeding your household? Never	In the past 12 months, have you been worried about feeding your household? Seldom, 1-3 times this past year	In the past 12 months, have you been worried about feeding your household? Sometimes, 4-5 times this past year	In the past 12 months, have you been worried about feeding your household? Often, every other month this past year or similar	In the past 12 months, have you been worried about feeding your household? Almost always, almost every month this past year
In the past 12 months, have you been able to make enough money to meet your family's basic needs?	In the past 12 months, have you been able to make enough money to meet your family's basic needs? Never	In the past 12 months, have you been able to make enough money to meet your family's basic needs? Seldom, 1-3 times this past year	In the past 12 months, have you been able to make enough money to meet your family's basic needs? Sometimes, 4-5 times this past year	In the past 12 months, have you been able to make enough money to meet your family's basic needs? Often, every other month this past year or similar	In the past 12 months, have you been able to make enough money to meet your family's basic needs? Almost always, almost every month this past year

Next we are going to ask you about several issues that may be impacting your household. Please select the response in the table that shows how serious each of the issues is for your household. If an issue is not a problem or does not apply to your household, choose “not a problem.”

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* 14. Housing

	Not a problem	Slight problem	Moderate problem	Serious problem	Very serious problem
Finding safe, affordable housing	Finding safe, affordable housing Not a problem	Finding safe, affordable housing Slight problem	Finding safe, affordable housing Moderate problem	Finding safe, affordable housing Serious problem	Finding safe, affordable housing Very serious problem
Having enough money to pay rent or mortgage	Having enough money to pay rent or mortgage Not a problem	Having enough money to pay rent or mortgage Slight problem	Having enough money to pay rent or mortgage Moderate problem	Having enough money to pay rent or mortgage Serious problem	Having enough money to pay rent or mortgage Very serious problem
Paying for heating and/or cooling	Paying for heating and/or cooling Not a problem	Paying for heating and/or cooling Slight problem	Paying for heating and/or cooling Moderate problem	Paying for heating and/or cooling Serious problem	Paying for heating and/or cooling Very serious problem
Insulating or weatherizing my house	Insulating or weatherizing my house Not a problem	Insulating or weatherizing my house Slight problem	Insulating or weatherizing my house Moderate problem	Insulating or weatherizing my house Serious problem	Insulating or weatherizing my house Very serious problem
Buying a house	Buying a house Not a problem	Buying a house Slight problem	Buying a house Moderate problem	Buying a house Serious problem	Buying a house Very serious problem
Fixing unsafe living conditions such as a leaking roof, toxic mold, lack or heat, or pests	Fixing unsafe living conditions such as a leaking roof, toxic mold, lack or heat, or pests Not a problem	Fixing unsafe living conditions such as a leaking roof, toxic mold, lack or heat, or pests Slight problem	Fixing unsafe living conditions such as a leaking roof, toxic mold, lack or heat, or pests Moderate problem	Fixing unsafe living conditions such as a leaking roof, toxic mold, lack or heat, or pests Serious problem	Fixing unsafe living conditions such as a leaking roof, toxic mold, lack or heat, or pests Very serious problem

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* 15. Employment

	Not a problem	Slight problem	Moderate problem	Serious problem	Very serious problem
Getting a better-paying job	Getting a better-paying job Not a problem	Getting a better-paying job Slight problem	Getting a better-paying job Moderate problem	Getting a better-paying job Serious problem	Getting a better-paying job Very serious problem
Getting a job with health insurance benefits	Getting a job with health insurance benefits Not a problem	Getting a job with health insurance benefits Slight problem	Getting a job with health insurance benefits Moderate problem	Getting a job with health insurance benefits Serious problem	Getting a job with health insurance benefits Very serious problem
Getting education or training to get a better job	Getting education or training to get a better job Not a problem	Getting education or training to get a better job Slight problem	Getting education or training to get a better job Moderate problem	Getting education or training to get a better job Serious problem	Getting education or training to get a better job Very serious problem

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* 16. Transportation

	Not a problem	Slight problem	Moderate problem	Serious problem	Very serious problem
Finding reliable transportation	Finding reliable transportation Not a problem	Finding reliable transportation Slight problem	Finding reliable transportation Moderate problem	Finding reliable transportation Serious problem	Finding reliable transportation Very serious problem
Buying a car	Buying a car Not a problem	Buying a car Slight problem	Buying a car Moderate problem	Buying a car Serious problem	Buying a car Very serious problem
Paying for car maintenance (insurance, gas, repairs)	Paying for car maintenance (insurance, gas, repairs) Not a problem	Paying for car maintenance (insurance, gas, repairs) Slight problem	Paying for car maintenance (insurance, gas, repairs) Moderate problem	Paying for car maintenance (insurance, gas, repairs) Serious problem	Paying for car maintenance (insurance, gas, repairs) Very serious problem

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* 17. Health

	Not a problem	Slight problem	Moderate problem	Serious problem	Very serious problem
Getting enough food to eat	Getting enough food to eat Not a problem	Getting enough food to eat Slight problem	Getting enough food to eat Moderate problem	Getting enough food to eat Serious problem	Getting enough food to eat Very serious problem
Getting medical care	Getting medical care Not a problem	Getting medical care Slight problem	Getting medical care Moderate problem	Getting medical care Serious problem	Getting medical care Very serious problem
Getting dental care	Getting dental care Not a problem	Getting dental care Slight problem	Getting dental care Moderate problem	Getting dental care Serious problem	Getting dental care Very serious problem
Experiencing anxiety or depression	Experiencing anxiety or depression Not a problem	Experiencing anxiety or depression Slight problem	Experiencing anxiety or depression Moderate problem	Experiencing anxiety or depression Serious problem	Experiencing anxiety or depression Very serious problem
Feelings of social isolation	Feelings of social isolation Not a problem	Feelings of social isolation Slight problem	Feelings of social isolation Moderate problem	Feelings of social isolation Serious problem	Feelings of social isolation Very serious problem

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* 18. Childcare

	Not a problem	Slight problem	Moderate problem	Serious problem	Very serious problem
Finding childcare	Finding childcare Not a problem	Finding childcare Slight problem	Finding childcare Moderate problem	Finding childcare Serious problem	Finding childcare Very serious problem
Paying for childcare	Paying for childcare Not a problem	Paying for childcare Slight problem	Paying for childcare Moderate problem	Paying for childcare Serious problem	Paying for childcare Very serious problem

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* 19. Financial and Legal Issues

	Not a problem	Slight problem	Moderate problem	Serious problem	Very serious problem
Lack of savings	Lack of savings Not a problem	Lack of savings Slight problem	Lack of savings Moderate problem	Lack of savings Serious problem	Lack of savings Very serious problem
Having enough money to pay all monthly bills	Having enough money to pay all monthly bills Not a problem	Having enough money to pay all monthly bills Slight problem	Having enough money to pay all monthly bills Moderate problem	Having enough money to pay all monthly bills Serious problem	Having enough money to pay all monthly bills Very serious problem
Repairing or building credit	Repairing or building credit Not a problem	Repairing or building credit Slight problem	Repairing or building credit Moderate problem	Repairing or building credit Serious problem	Repairing or building credit Very serious problem
Getting a loan with an affordable interest rate	Getting a loan with an affordable interest rate Not a problem	Getting a loan with an affordable interest rate Slight problem	Getting a loan with an affordable interest rate Moderate problem	Getting a loan with an affordable interest rate Serious problem	Getting a loan with an affordable interest rate Very serious problem
Paying the telephone bill	Paying the telephone bill Not a problem	Paying the telephone bill Slight problem	Paying the telephone bill Moderate problem	Paying the telephone bill Serious problem	Paying the telephone bill Very serious problem
Paying off debt	Paying off debt Not a problem	Paying off debt Slight problem	Paying off debt Moderate problem	Paying off debt Serious problem	Paying off debt Very serious problem
Getting legal advice	Getting legal advice Not a problem	Getting legal advice Slight problem	Getting legal advice Moderate problem	Getting legal advice Serious problem	Getting legal advice Very serious problem

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* 20. Have you heard of CAP Services?

Yes

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* 21. Have you used a CAP Services program in the past year?

Yes

Don't know

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* 22. What can CAP Services do to help?

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* 23. Are you currently a migrant farmworker (this means you travel away from your permanent residence to work in agriculture and are unable to return home the same day)?

Yes

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* 24. Are you currently a seasonal farmworker (this means you work in seasonal or temporary farm work, but you are not required to be away from your permanent residence overnight)?

Yes

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* 25. Entry Form for a chance to win a $20 Gift Card! (optional)

Name

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number