Household Socioeconomic Survey

Household Socioeconomic Survey
Please complete this survey to help us understand your household's demographic and economic situation. Your responses will remain confidential and are used for research and planning purposes only.
Head of Household Full Name
First NameLast Name
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Household Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Number of People Living in the Household

Household Members: Please provide details for each member of your household.

Highest Education Level Attained in the Household
Main Source of Household Income
Other
Monthly Household Income (approximate)
Type of Housing
Other
Housing Ownership Status
Other
Which of the following basic services does your household have access to? (Select all that apply)
Which of the following assets does your household own? (Select all that apply)
Other
Does anyone in your household receive government assistance?
How would you rate your household's overall well-being?

1
2
3
4
5
1 is Very Poor, 5 is Excellent
Please provide any additional comments or information about your household's socioeconomic situation.
Should be Empty:

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