Community Life Questionnaire (CLQ)
Pedestal/Marshall Gardens residents. Please complete this form so that we can learn more about what the needs of the community area. Residents who COMPLETE this will have an opportunity to win 1 of 5 $25 gift-cards.
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Your Name *
Your address *
What is your phone number AND email (if you have one) *
I agree complete this form *
Required
How safe do you feel in your apartment building? *
How safe do you feel in your community? *
Do you agree or disagree with the following statement? "I feel valued in my community. *
Are you registered to vote *
Did you vote in the last election? *
Which of the following applies to you? (check all that apply) *
Required
If you are working for pay are you working full or part time. *
Would you say that in general your health is? *
Do you have a one person you think of as your personal doctor or health care provider? *
As of today, what type of health insurance do you have? *
About how long has it been since you visited a doctor for a routine checkup? A routine checkup is a general physical exam that can be conducted either in-person or through a tele-health video chat or phone call. A routine check up is not an exam for a specific injury, illness, or condition. *
During the past 12 months, how many times have you gone to the hospital emergency department? *
Within the past 12 months we were worried whether our food would run out before we got money to buy more *
Within the past 12 months the food we bought just didn't last and we didn't have money to get more *
 How often do you feel isolated from others *
If you do feel isolated, who do you turn to? (check all that apply) *
Required
COMPLETE ONLY IF your  age 63 or over, disabled, and/or has a chronic medical condition? (check all that apply) IF your are YOUNGER than 63 SKIP to RATING PEDESTAL/ MARSHALL GARDENS DEPARTMENTS. *
Required
Do you have autoimmune disease (lupus, celiac, severe allergies, etc.) *
Cancer *
Chronic lung or respiratory disorder (asthma, COPD, or etc.) *
Chronic pain (sciatica, fibromyalgia, chronic headache, chronic migraine, etc.) *
Dental issue (mouth sores, gum disease, etc.) *
Diabetes or high blood sugar *
Ear or Hearing problem (hearing loss, vertigo, etc.) *
Eye condition (cataracts, glaucoma, macular degeneration, etc.) *
Heart condition (heart attack, anemia, etc.) *
High blood pressure or hypertension *
Joint or bone disorder (arthritis, rheumatism, osteoporosis, podiatric/foot disorder, etc.) *
Mental Health Condition (anxiety, depression, ADD, PTSD, etc.) *
Neurological Condition (stroke, ALS, seizures, multiple sclerosis (MS), etc.) *
Do you have any functional limitations because of this condition? *
How confident are you that you can manage this condition in the long term? *
Organ System Condition (Inflammatory Bowel Disease (IBS), bladder issue, kidney disease, liver disease, thyroid disease, etc.) *
Other *
Can you bath by yourself *
Can you dress yourself *
Can you get out of the bed/chair  by yourself *
Can you shop by yourself *
Can you prepare meals by yourself *
Can you do laundry by yourself *
Can you manage your medication
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Can you manage your own money and pay your bills? *
Can you manage your chronic illnesses *
RATE your overall living experience at Pedestal/Marshall Gardens? )0=Not likely; 10 Likely *
Required
Community Life (with Meloni/Interns) *
Property Management *
Maintenance *
 Do you have children/youth in your household age 0-17 *
If YES, list child's name, school, age, AND is your child attending an after school program *
Do you have children ages 18-24 and older, if yes please indicate his/her name? *
If your child ages 18-24 in a Workforce program, school, working? IF yes, please indicate. *
Is EVERY child covered by health insurance? If yes, please indicate what the insurance carrier is (ex: Jai, Medical Assistance, Kaiser etc... *
I am comfortable with the neighbors in my building *
People generally get along in this building. *
People in this building care about keeping it safe, clean, and a good place to live. *
Do you have a computer, laptop, or tablet in your household? *
How often is a computer, laptop, or a tablet available to children for educational purposes? (Select only one answer) *
Do you have access to the internet in your apartment *
How often is your apartment internet connection reliably available to children for educational purposes meaning it doesn’t drop out or freeze during videos, teacher lectures, and/or other school related work? (Select only one answer) *
How has your life been impacted by the COVID-19 pandemic? (Check all that apply) *
Required
What are barriers that prevent your child or children from attending school everyday? *
What are barriers impacting your child or children's academic performance? *
During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities such as self-care, work, or recreation? *
Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days, how many days was your physical health not good? *
Thinking about your mental health, which includes stress, depression and problems with emotions, for how many days during the past 30 days was your mental health not good? *
Some people may not be able to get a job even if they want to work. Other people have personal or other reasons for not working for pay. What is the main reason you are not working? *
During the past 12 months, did you work for pay *
Are you currently looking for paid work? (Looking for paid work could be enrolling in a vocational training program, work preparation program, or actively applying to jobs) *
In the past 12 months, did you take any vocational training courses for a specific trade or occupation? *
Did you successfully complete the vocational training program you were in *
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