Community Pulse Survey

1
What is your zip code?* This field is required.
2
Which best describes your household?* This field is required.Choose all that apply.
Adults only
Children Ages 6-12
Children Ages 0-5
Youth Ages 13-17
Young Adults Ages 18-24
Adults Ages 60+
Prefer not to answer
3
How many people live in your household?* This field is required.
1
2
3
4
5
6 or more
Prefer not to answer
4
What is your age range?* This field is required.
Under 18
18-24
25-34
35-44
45-54
55-64
65+
5
What is your household's approximate annual income?* This field is required.
Less than $15,000
$15,000-$24,999
$25,000-$34,999
$35,000-$49,999
$50,000-$74,999
$75,000-$99,000
$100,000 or more
Prefer not to answer
6
How do you describe your race and/or ethnicity?* This field is required.Choose all that apply.
American Indian or Alaskan Native
Black or African American
Middle Eastern or North African
White
Asian
Hispanic or Latino
Native Hawaiian or Pacific Islander
Another race / ethnicity
7
How do you describe your gender?* This field is required.
Please Select
Please Select
Woman
Nonbinary / another gender
Man
Prefer not to answer
8
What are the THREE biggest challenges your household is dealing with RIGHT NOW?* This field is required.
Affordable housing
Utilities / Energy Costs
Employment
Transportation
After School or Summer Care
Job Training or Education
Mental Health
Safety
Legal Assistance
Rent/Mortgage
Food
Income/Financial Stability
Childcare
Education/School Support
Healthcare
Substance Abuse/Addiction Services
Internet/Technology Access
None of these
Other
9
Thinking about your community, what are the THREE biggest needs you see?* This field is required.
Affordable housing
Utilities/Energy Assistance
Employment Opportunities
Transportation
After School or Summer Programs
Prefer Not to Answer
Job Training or Education
Mental Health Services
Community Safety
Legal Assistance
Rent/Housing Stability
Food Access
Income/Financial Stability
Childcare
Education/School Support
Healthcare
Substance Abuse/Addiction Services
Internet/Technology Access
Services For Older Adults
None of these
10
What makes it difficult for you or people you know to get help when it is needed?* This field is required.Check all that apply.
Cost
Programs are too far away
Long waiting lists
Eligibility requirements
Childcare
Internet/Technology
Services are not available in my community
Transportation
Program hours do not work for me
Do not know where to go for help
Too much paperwork
Language barrier
Difficulty reaching agencies
Concern about asking for help
Nothing makes it difficult
Other
11
What is the one service, resource or opportunity you wish were easier to find or access in your community?* This field is required.
12
The next section is separate from the Community Pulse Survey. Complete it ONLY if you would like someone from First State Community Action Agency to contact you with information about programs or services.

PRIVACY NOTE: Contact information provided here will only be used for requested follow-up and is not required to complete the Community Pulse Survey.
13
Would you like to continue?* This field is required.
Yes
No
14
Please provide you full name.* This field is required.
First Name
Last Name
15
Please provide the best number to reach you.* This field is required.
Please enter a valid phone number.
16
Please provide your Email address.* This field is required.
example@example.com
17
What would like more information about?* This field is required.
Housing/Home Ownership
Utility/Energy Assistance
Employment/Job Training
Youth Programs
Financial Education
Reentry Program
Rent/Housing Stability
Food
Education
Childcare
Senior Services
Other
18
This completes our survey!

Thank you for participating.
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