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In the past year, have you or someone you know (check all that apply)

Page One

1. Struggled to find employment?
2. Been unable to provide for the basic needs of the family because of low wages/income?
3. Had difficulty making a mortgage or rent payerment that resulted in the threat of eviction or foreclosure?
4. Been underwater on a mortgage (i.e. the mortgage is more than the house's current value)?
5. Had difficulty finding high-quality, affordable childcare?
6. Struggled to find employment or housing because of a misdemeanor or felony conviction? (please include expungements)
7. Been separated from family members or denied opportunity because of immigration status?
8. Had difficulty getting to work, school, church or other activities because of a lack of transportation?
9. Been uninsured or under-inured for health care?
10. Had a child experience unfair, harsh or excessive discipline at school?
11. Experienced domestic violence?
12. Been injured by a gun (including accidental, self-inflicted harm or death)?
13. Experienced financial hardship because of a birth or medical emergency?
14. Found that your school district has inadequate resources to provide for all of your children's educational needs?
15. Suffered because a loved on is incarcerated?
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