Please complete this survey ONLY if you are a resident of Schoharie County.

Thank you for participating in our survey.  This information will be used to help SCCAP better identify the needs of our community.  Your identify and answer will remain confidential.

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* 1. Today's Date

Date

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* 2. Please provide your zip code

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* 3. How long have you been a Schoharie County resident?

Please answer the following questions by placing a "check" or "X" in the box next to the most accurate answer.


DEMOGRAPHIC information

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* 4. Which describes you and your relationship to Schoharie County Community Action Program? (check all that apply)

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* 5. What is your age group?

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* 6. Are you disabled?

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* 7. Are you a veteran?

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* 8. Do you have health insurance?

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* 9. How have you retained your health insurance?

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* 10. Are you satisfied with your healthcare plan?

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* 11. What is your monthly gross (before taxes) household income?

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* 12. Do you receive income from any of the following sources? (check all that apply)

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* 13. What is your ethnicity/race?

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* 14. How would you describe your family type?

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