Education |
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Educational attainment (4) |
What is the highest level of education you completed? |
□ No formal schooling □ Primary school □ Secondary school (high, tech etc.) □ Tertiary □ Other (please specify): ___ |
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Literacy and health literacy (10) |
Do you ever need help understanding what your doctor tells you, or help reading health information? |
□ Yes □ No |
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Child education (11) |
Do you have concerns about your child’s learning or school performance? |
□ Yes □ No |
Economic stability |
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Employment status (14) |
What is your current work situation? |
□ Unemployed □ Part-time or temporary work □ Full-time work □ Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver) □ Other, please write: ______ □ I choose not to answer |
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Financial stability (27) |
How would you say you are managing financially at the moment? How hard is it for you to pay for the very basics like food, housing, medical care, and heating? |
□ Living comfortably □ Getting by □ Finding it difficult □ Not hard at all □ Not very hard □ Somewhat hard □ Hard □ Very hard □ Prefer Not to Answer |
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Income (1) |
What is your average weekly household income? |
__ (select option e.g. □ $25,000–$39,999 □ $40,000–$55,000….) |
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Financial support (2) |
What is your primary source of financial support? |
□ Self □ Spouse/Partner/Significant Other □ Parent □ Disability (SSI or SSD) □ Government/Public Assistance □ Social Security Retirement □ Retirement (not social security) □ Other (please specify) □ Do not know/unable to answer |
Social and community context |
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Marital/living status (7) |
Which of the following best describes your living arrangements? |
□ Live with partner only □ Live with partner and children □ Sole parent with children □ Live with parents/other related adults □ Live with unrelated adults □ Other, please specify: _ |
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Social support—personal (24) |
In a typical week, how many times do you talk on the telephone with family, friends, or neighbours? |
□ Never □ Once a week □ Twice a week □ 3 times a week □ More than 3 times a week |
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Social support—community (24) |
How often do you attend meetings of the clubs or organizations you belong to? |
□ Never □ 1 to 4 times per year □ more than 4 times per year |
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Community programs (10) |
In the last 12 months, have you received assistance from an organization or program to help you with any of the following? |
□ None □ At least 1: □ Transportation □ Paying utility bills □ Education □ Food □ Paying for medications □ Childcare □ Housing □ Job search or training □ Care for elder or disabled |
Health and clinical care |
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Access and affordability (19) |
Have you needed to see a doctor but could not because it costs too much? |
□ Yes □ No |
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Health insurance (4) |
How stressful do you find concerns about lack of health insurance or inadequate insurance? |
□ Not at all stressful □ A little bit stressful □ Moderately stressful □ Very stressful □ Extremely stressful □ Issue listed is not relevant to my family |
Neighbourhood and physical environment |
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Housing status (13) |
Which of the following best describes your current living situation? |
□ House □ Flat, unit or apartment □ Retirement village □ Caravan or mobile home □ Housing trust □ Supported accommodation □ Other, please specify:__ |
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Housing insecurity (35) |
How concerned are you that you will not have a place to live sometime in the next 6 months? |
□ Very concerned □ Somewhat concerned □ Not concerned □ I choose not to answer |
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Home environment/safety (23) |
Think about the place where you live. Do you have problems with any of the following? |
Pests (mice or roaches), mould, no/not working smoke detectors, water leaks, no window guards? □ Yes □ No |
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Neighbourhood safety (3) |
Do you feel safe in your neighbourhood? |
□ Never □ Rarely □ Sometimes □ Often □ Always □ Not Applicable |
Food insecurity |
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Food (in)sufficiency (50) |
In the past month, did anyone in your family go hungry because there was not enough money? |
□ Yes □ No |
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Healthy food access/affordability (30) |
How often is client able to afford to buy healthy food for themselves and family? |
□ Never □ Rarely □ Sometimes □ Often □ Always □ Not Applicable |
Utility needs |
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Difficulty paying bills (17) |
In the past 12 months, have you worried that any utility (electric, gas, water or oil) would be shut off for not paying your bills? |
□ Yes □ No □ Already shut off □ I prefer not to answer |
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Problems with utilities (5) |
Are you currently having issues at home with your utilities, such as your heat, electric, natural gas or water? |
□ Yes □ No |
Transportation barriers |
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Impact on medical appointments (21) |
In the last 12 months, has lack of transportation kept you from medical appointments or from getting medications? |
□ Yes □ No |
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Other access barriers (8) |
In the past 12 months, has lack of transportation kept you from meetings, work, or getting things needed for daily living? |
□ Yes □ No □ Prefer not to answer |
Interpersonal violence or safety |
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Safety—general (2) |
Do you feel unsafe in your daily life? |
□ Yes □ No |
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Safety at home (5) |
Are you or your family worried about feeling safe in your home? |
□ Yes □ No |
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Safety in relationships (30) |
Do you feel that you and/or your children are safe in your relationships? |
□ Yes □ No |
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Safety in neighbourhood (2) |
Do you have concerns about safety in your neighbourhood? |
□ Yes □ No |
Stress |
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General stress (8) |
Stress means a situation in which a person feels tense, restless, nervous or anxious or is unable to sleep at night because his/her mind is troubled all the time. Do you feel this kind of stress these days? |
□ All of the time □ Most of the time □ Some of the time □ A little of the time □ None of the time |