Ask for Contact Name
1 = YES

Received Letter
1 = NO QUESTIONS

Appreciate your cooperation.
1 = OK

Verify agency name
1 = YES
2 = NO
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Program or agency?
1 = PROGRAM
2 = AGENCY
3 = BOTH
4 = OTHER
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

PROGRAMS WITHIN AGENCIES STATEMENT
1 = CONTINUE

Private or public?
1 = PRIVATE
2 = PUBLIC
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

City, county, state, or federal government?
1 = CITY
2 = COUNTY
3 = STATE
4 = FEDERAL
5 = COMBINATION
6 = OTHER
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Grant monies funding
1 = YES
2 = NO
3 = PARTIALLY
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Grant money proportion
1 = < 1/3
2 = 1/3 to 2/3
3 = > 2/3
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Take services to clients?
1 = TAKE TO CLIENTS
2 = CLIENTS COME
3 = BOTH
4 = OTHER
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Amount of materials in non-English?
1 = ALL
2 = MOST
3 = SOME
4 = NONE
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Who translates?
1 = FAMILY
2 = AGENCY STAFF
3 = OTHER STAFF
4 = SOMEONE ELSE
5 = NO TRANSLATION
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Physical disability access?
1 = YES
2 = NO
3 = PARTIAL YES
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

1 = MALES ONLY
2 = FEMALES ONLY
3 = NO
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Services free?
1 = FREE
2 = PAY FEE
3 = DEPENDS
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Could serve more clients on current budget?
1 = YES
2 = NO
3 = MAYBE
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Provide service directly?
1 = PROVIDE
2 = HELP GET
3 = OUTSIDE SCOPE
4 = PROVIDE & GET
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Barriers: Clients not knowing services available
1 = OFTEN
2 = SOMETIMES
3 = RARELY
4 = NEVER
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Barriers: Inability to pay costs and fees for service?
1 = OFTEN
2 = SOMETIMES
3 = RARE
4 = NEVER
7 = REFUSED
8 = DON'T KNOW
9 = NO ANSWER

Part of Gov't
1 = City or County
2 = Other
7 = DK/NA/REF
8 = DK/NA/REF
9 = DK/NA/REF

Who translates?
1 = Family
2 = Agency
3 = Other
7 = DK/NA/REF
8 = DK/NA/REF
9 = DK/NA/REF

1 = YES
2 = NO
7 = DK/NA/REF
8 = DK/NA/REF
9 = DK/NA/REF