Community Needs and Housing Survey
Although the staff and leadership at Adaptt Rochester, Inc. are familiar with assisting people in the community who have been affected by poverty and housing instability, we feel it is essential to providing the most effective services to find out what the community needs are by asking the community. Please help us to know how to best serve the Rochester area population by completing this survey. Answers are anonymously captured unless you choose to enter your personal details. Also, please feel free to share with your friends and family in the Rochester area. We thank you for taking the time to answer these questions. 
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Email Address **Optional**
What is your zip code? *
What is your annual income? *
Are you working? *
What race do you identify? *
What gender do you identify? *
Do you have any other identifying qualities you would like to share? (ie: Member of the LGBTQIA+ community)
Do you have children? *
How many children do you have in your care (you are the main provider and caretaker, they live in your home) *
Required
Have you experienced housing instability in the past five years?   *
What type of housing instability have you experienced? *
Required
How many times have you experienced housing instability in the last 5 years? *
In the last five years, have you fallen behind on more than one housing payment? (rent or mortgage) *
If yes, how many times?
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Have you lacked a proper bed? (Mattress, not including air mattress, couch, futon) *
If you have children in your custody, have they lacked a proper bed? (Mattress, not including air mattress, couch, futon or shared bed with family) *
Have you experienced food insecurity? (Not having enough food in the home) *
If yes, did you know what resources were available to receive free food? (food pantry, community food cupboard, free prepared meals) *
Do you have enough clean / well fitting clothes for a weeks worth of wearing, including undergarments? *
Do your children have enough clean / well fitting clothes for a weeks worth of wearing, including undergarments? *
What is your main mode of transportation? *
Do you have health insurance? *
Do you have a primary care physician? *
If you have children in your care, do they have health insurance? *
If you have children in your care, do they have a primary care physician? *
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