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Please provide us with the following information about yourself: <br /> RACE/ETHNICITY: <br />AGE: ________ GENDER: _____________ <br /> <br />EMPLOYMENT STATUS: <br /> Employed <br />part time <br /> Student <br /> Disabled <br /> Employed <br />full time <br /> Unemployed <br /> Retired <br /> Employed <br />and <br /> student <br /> Stay-at- <br />Home <br /> Self <br />Employed <br /> <br /> Occupation: ______________________________________ <br /> <br />6. How can we improve the services that Basic Needs provides? <br />Suggestions:___________________________________________________________________________ <br />_______________________________________________________________________________________ <br />__________ <br />Thank you for your time and input. <br />Your feedback will help us with our programs and our growth! <br /> <br /> <br /> <br /> <br /> <br /> African American/Black <br /> Anglo/Caucasian/White <br /> Asian/Pacific Islander <br /> Hispanic/Latina <br /> Native American <br /> Other: <br />________________________ <br /> Mixed Race <br />