Income and Benefits Participation Survey
Please answer the following questions to help us understand income sources and benefit participation.
Full Name
*
First Name
Last Name
What is your age group?
*
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
What is your highest level of education completed?
*
Please Select
Less than high school
High school diploma or equivalent
Some college
Associate degree
Bachelor's degree
Graduate or professional degree
What is your current employment status?
*
Employed full-time
Employed part-time
Self-employed
Unemployed
Retired
Student
Other
What are your sources of income? (Select all that apply)
*
Wages or salary
Self-employment
Retirement or pension
Unemployment benefits
Disability benefits
Social assistance
Investment income
Family support
Other
Please indicate your participation in the following benefit programs.
*
Rows
Currently Participating
Previously Participated
Never Participated
Unemployment Insurance
1
2
3
Disability Benefits
4
5
6
Retirement/Pension Plan
7
8
9
Employer Health Insurance
10
11
12
Government Health Insurance
13
14
15
Food Assistance
16
17
18
Housing Assistance
19
20
21
How satisfied are you with the benefits you receive?
*
Not satisfied
1
2
3
4
Very satisfied
5
1 is Not satisfied, 5 is Very satisfied
If you are not participating in some benefits, what are the main reasons?
Not eligible
Not aware of the program
Application process too complicated
Do not need the benefit
Other
What is the total number of people in your household?
*
Please provide any additional comments or suggestions regarding income and benefits.
Email address (optional, if you wish to receive follow-up information)
example@example.com
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