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* 1. Please provide your name

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* 2. Enter your phone number

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* 3. Enter your email address

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* 4. Where do you reside?

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* 5. Including yourself, select the box below for all the ages who reside in
your household (Select all that apply):

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* 6. What is your gender?

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* 7. Are you currently employed?

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* 8. Which is the following methods is best for GHA to contact you? (Select all that apply)

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* 9. Do you have connection issues or problems with your internet access in the community/apartment where you reside?

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* 10. Do you agree or disagree with the following statement: My family has access to the technology needed to access the internet effectively.

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* 11. What type of programs and services would you or members of your household most likely participate in? (Select all that apply):

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* 12. What are the best days to offer programs? (Check at least two boxes)

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* 13. What are the primary health care needs of your household? (check all that apply)

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* 14. What are the things that make it difficult for you or other adults in your household to find and/or keep work? (check all that apply)

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