Today's Date: *

How did you hear about this survey? *

1. Name: *

2. Age: *

3a. Number of children: *

3b. Age/s of children: *

4a. Where were you born? *

4b. When did you move to Utah?

4c. Current city of residence? *

4d. How long have you lived at your current residence? *

5. Have you ever had difficulty finding affordable housing? Please describe briefly: (if you haven't, skip to question 6)

6. Have you ever experienced a crisis that left you without a place to live? Please describe briefly: (if you haven't, skip to question 7)

7. What has, or currently helps you to stay in an apartment or home? (i.e. livable wages, quality and affordable housing, a nearby job, etc.) *

8. If you work, approximately how much income does your job bring in per month? (if you don't work, please answer question 9a next)

9a. Are you currently receiving assistance from any of the following (select all applicable): *

9b. Any other services (not listed above) currently using? (i.e. food pantries, Donated Dental, etc.)

10a. If you receive income that does not come from a job, where does this come from? Describe briefly: (if not, skip to question 11)

10b. Monthly income from this source?

11. Have you had any formal education or job training? Describe briefly, including any degrees or education/job training attained: (if not, skip to question 12)

12. Has anyone from the Department of Workforce Services (DWS) spoken with you about job training? *

13. Have you spoken to someone from any of these agencies? (select all applicable) *

14. What services, assistance and/or programs, including any education or job training, have been most helpful for you? *

15. Have you ever had to move due to any kind of violence? Please describe briefly: (if you haven't, skip to question 16)

16. Have you ever had to pay any fees while searching for an apartment or home? Please describe briefly, and include any difficulty you've had with paying the fees: (if you haven't, skip to question 17)

17. Have you ever been evicted? Please describe briefly: (if you haven't, skip to question 18)

18. What do you think helps homeless and low-income individuals the most? (i.e. quality and affordable housing, healthcare and education/job training, affordable childcare, etc.) *

19. Would you like to participate in a longer discussion about how to empower homeless and low-income moms and families? *

20. Which of these interest you the most? (select all applicable) *

21. What other issues (not listed above) interest you? Describe briefly:

22. What resources would make your life easier now, during COVID? What new ways of doing things might be helpful?

23. What is the best way to contact you? *

Your phone/ cell number:

Your email:

Thank you for taking the time to fill this survey out! ☺ Your valuable information is greatly appreciated, and helps us to better meet individuals in need within the community. Questions, concerns, or comments? Please contact Jess Roadman or Audrey Mancini at: powerfulmomswhocare@gmail.com / (801) 364-7765 x. 110 or ask us questions and/or leave concerns or comments below.