1. Washington, Iron, Beaver, Garfield, and Kane Counties

Thank you for providing input on needs of the community. The data collected through this survey will be used to inform community leaders about issues facing your County and used to evaluate existing/future program(s) from non-profit and public agencies.

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* 1. What is your race?

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* 2. Select your gender

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* 3. What is your age?

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* 4. What is your household type

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* 5. What is your household size:

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* 6. What county do you currently live in?

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* 7. What is your education level?

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* 8. Please select your household income

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* 9. Select the answer that best describes your type of income:

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* 10. What is your current housing situation?

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* 11. Have you received any third party help for rent and/or utilities?

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* 12. What would make you feel safer in your home and/or neighborhood? (Check all that apply)

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* 13. Does everyone in your household have health insurance?

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* 14. Do your household expenses exceed your household income?

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* 15. If you received a tax refund this year, how did you spend it? (Check all that apply)

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* 16. What is preventing you from furthering your education? (Check all that apply)

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* 17. Are you aware of community resources for physical health concerns?

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* 18. Are you aware of community resources for mental health concerns?

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* 19. Do you have safe and reliable transportation to get where you need/want to go? (Check all that apply)

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* 20. Does your household have: (check all that apply)

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* 21. Rank categories in order of most needed to you and your family, 1 being the least and 7 being the most.

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* 22. Please input your email address.

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