1.)
Please identify your community (i.e. Eldora, Iowa Falls,
Hubbard, etc.)
2.) How
long have you lived in Hardin County?
0-5 years
6-10 years
11-15 years
16-24 years
+25 years
Please
answer the following questions on a scale of 1-10, with
10 representing the most positive, and 1
being most negative.
3.)
Overall, how would you value your community as a place to
live?
1-10
1
2
3
4
5
6
7
8
9
10
4.) How would you
value your community as a place to raise a family?
1-10
1
2
3
4
5
6
7
8
9
10
5.)
Over the next few years, do you think the quality of life
will:
Improve A Great Deal
Improve Slightly
Stay the Same
Grow A Little Worse
Grow Much Worse
6.) Overall, how would you
rate the social environment in your community (such as the
friendliness of the people, the way people respect each
other, the way people help out one another, and the
willingness of the people to work for the good of the
community)?
1-10
1
2
3
4
5
6
7
8
9
10
7.) Do
you believe that you, as an individual, are able to affect
the quality of life in your community?
1-10
1
2
3
4
5
6
7
8
9
10
Please answer the following questions
on a scale of 1-10excellent --------1 being very poor .
8.) Availability of
public transportation.
1-10
1
2
3
4
5
6
7
8
9
10
9.) Affordability of
public transportation in your community.
1-10
1
2
3
4
5
6
7
8
9
10
10.) Availability of
affordable housing for rent in your community.
1-10
1
2
3
4
5
6
7
8
9
10
11.) Availability of
affordable housing for purchase in your community.
1-10
1
2
3
4
5
6
7
8
9
10
12.) Availability of
quality housing for rent in your community.
1-10
1
2
3
4
5
6
7
8
9
10
13.) Availability of
quality housing for purchase in your community.
1-10
1
2
3
4
5
6
7
8
9
10
14.) How would you
rate the services that help families experiencing housing
issues (inability to pay mortgage, rent, utilities,
homelessness, etc.)
1-10
1
2
3
4
5
6
7
8
9
10
15.) In
the past year, did you or a member of your family, use/visit
any of the following?
public park in your community
public park in a neighboring community
state park
indoor recreational facility in your county
outdoor recreational facility in your county
museum in your community
your local library
local tourist attraction
the Hardin County Fair
the fair grounds or community building for reason other than
the Fair
a community celebration (such as Alden Egg Days, Riverbend
Rally, etc.)
a movie theater
other:
Please
answer the following questions on a scale of 1-10excellent ------ 1 being very poor .
16.) How
would you rate the availability of activities, recreational
facilities, and entertainment offerings for families in your
community?
1-10
1
2
3
4
5
6
7
8
9
10
17.)
Please rate the availability of outdoor recreational options
in your community:
1-10
1
2
3
4
5
6
7
8
9
10
18.) In
your opinion, what is your community’s greatest strength?
19.) What is your community’s greatest need?
Please rate the following services on a
scale of 1-10, with 10 representing excellent and 1
being very poor .
20.) Mental Health services
1-10
1
2
3
4
5
6
7
8
9
10
21.)
Substance Abuse services
1-10
1
2
3
4
5
6
7
8
9
10
22.)
Tobacco Cessation services
1-10
1
2
3
4
5
6
7
8
9
10
23.)
Child Care services
1-10
1
2
3
4
5
6
7
8
9
10
24.)
Nutritional/Weight Management services
1-10
1
2
3
4
5
6
7
8
9
10
25.)
Prenatal Care
1-10
1
2
3
4
5
6
7
8
9
10
26.)
Disability services
1-10
1
2
3
4
5
6
7
8
9
10
27.) Transportation services
1-10
1
2
3
4
5
6
7
8
9
10
28.)
Financial/Food Assistance
1-10
1
2
3
4
5
6
7
8
9
10
29.)
Veteran/Military Services
1-10
1
2
3
4
5
6
7
8
9
10
30.) Other services:
1-10
1
2
3
4
5
6
7
8
9
10
Community Leadership : excellent, 1
being very poor and N/A as not applicable .
31.)
Your city government.
1-10
1
2
3
4
5
6
7
8
9
10
NA
32.)
Hardin County government
1-10
1
2
3
4
5
6
7
8
9
10
33.) Local (city) law enforcement
1-10
1
2
3
4
5
6
7
8
9
10
NA
34.)
Hardin County law enforcement
1-10
1
2
3
4
5
6
7
8
9
10
35.)
Please rate the safety, security, and crime control in your
community.
1-10
1
2
3
4
5
6
7
8
9
10
36.) In
your opinion, what is your community leadership’s greatest
strength?
1-10
1
2
3
4
5
6
7
8
9
10
37.)
What is your community leadership’s greatest need?
1-10
1
2
3
4
5
6
7
8
9
10
38.) Do
you have a physician, in Hardin County that you can see for
routine appointments?
Yes
No
39.) Do
you have a physician or hospital, in Hardin County that you
can use for emergency/non-routine medical situations?
Yes
No
40.) Do
you have access to medical specialists (neurologist,
cardiologist, gynecologist, urologist, etc.) if necessary?
Yes
No
41.) Do
you have a dentist that you see on a regular basis (at least
annually)?
Yes
No
42.) Do
you have health insurance?
Yes
No
If No Explain
43.) Do
your children have health insurance?
Yes
No
If No Explain
44.) Do
you have dental insurance?
Yes
No
If No Explain
45.) Do
your children have dental insurance?
Yes
No
If No Explain
46.) Do
you have vision insurance?
Yes
No
If No Explain
47.) Do
your children have vision insurance?
Yes
No
If No Explain
48.) Are
you currently pregnant or have you given birth with in the
past 12 months?
Yes
No
If
yes, did you have prenatal care in the 1st and 9th
months of pregnancy?
Yes
No
If No Explain
Please rate the following services on a
scale of 1-10, with 10 representing excellent and 1
being very poor .
49.) Quality child
care (home and/or center based)
1-10
1
2
3
4
5
6
7
8
9
10
50.) Affordable
child care
1-10
1
2
3
4
5
6
7
8
9
10
51.) Quality
preschool
1-10
1
2
3
4
5
6
7
8
9
10
52.) Affordable
preschool
1-10
1
2
3
4
5
6
7
8
9
10
53.)
Please indicate the age(s) of children in your family and
what form of child care is used during work/school.
Age 0-2
Years
Parent
PreKindergarten/JuniorKindergarten
Preschool
Home Based Child Care
Family/Friend
Home Alone
Child Care Center
Age 3-5 years
Parent
PreKindergarten/JuniorKindergarten
Preschool
Home Based Child Care
Family/Friend
Home Alone
Child Care Center
School-aged
Before
school
Parent
PreKindergarten/JuniorKindergarten
Preschool
Home Based Child Care
Family/Friend
Home Alone
Child Care Center
School-aged
After school
Parent
PreKindergarten/JuniorKindergarten
Preschool
Home Based Child Care
Family/Friend
Home Alone
Child Care Center
54.) How many times
per week does your family eat a meal together at the table?
0-2 Times
3-5 Times
7 Times
N/A
55.) What is your
family’s greatest strength?
56.) What is your
family’s greatest challenge?
57.) What is your
family’s greatest need?
Education and Employment :
Please rate the following statements on
a scale of 1-10, with 10 representing strongly agree
and 1 being strongly disagree .
58.) The schools in
my community prepare youth for the job market and/or
college.
1-10
1
2
3
4
5
6
7
8
9
10
59.) The schools in
my community are safe environments for children.
1-10
1
2
3
4
5
6
7
8
9
10
Please answer the following questions
on a scale of 1-10, with 10 representing excellent
and 1 being very poor .
60.) Availability of jobs in my community
that pay above minimum wage
1-10
1
2
3
4
5
6
7
8
9
10
61.)
Availability of jobs for adolescents.
1-10
1
2
3
4
5
6
7
8
9
10
62.)
Additional comments regarding educational and/or employment
opportunities within your community or Hardin County:
Information about you :
63.) What year were you born?
64.) Number of adults (> 18 years) currently
living in your household:
65.) Number of
children (< 18 yrs.) currently living in your household:
0-2
Years Old 3-5
Years Old 6-10
Years Old 11-17Years
Old N/A
66.) Number of
children, aged 6-10 years in your household
attending:
Public
School Private
School Home
School N/A
67.) Number of
children, aged 11-17 years in your household attending:
Public
School Private
School Home
School Dropped
Out N/A
68.) Which best
describes your living situation?
Living in a home that I own or am buying
Living in a house/apartment that I rent
Living with relatives
Living with friends
No current home
69.) Marital status
Married
Divorce/Separated
Widowed
Single
Co-habitating
70.) Educational
level
11th grade or under
GED
HS Diploma
Some college
Associates Degree
Bachelors Degree
Masters Degree or Beyond
71.) Employment
status:
Full Time
Part Time
Employed at Multiple Jobs
Unemployed
Retired
Student
Unable to Work - Please Explain
Unable to
Work Explanation
72.) Income level of
household:
under $15,000
$15,001 - $30,000
$45,001 - $60,000
$60,001 - $75,000
$75,001 - $90,000
$90,001 - $105,000