1. If you could change one thing about the welfare system, what would it be?
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2. What do you feel is the major problem women face in their lives?
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3. Please rate the following issues on a scale of 1 to 10 with 1 being least important and 10 being very important:

child care _____
job training _____
child suppport _____
my education _____
health care _____
good jobs _____
my children's education _____
affordable housing _____
improving services at welfare office _____
raising welfare grants _____
improving "self-sufficiency" program _____
Are there any issues important to you that are not on this list?
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4. Have you had any problems with any of these issues yourself?
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5. Would you like to work with other women to find solutions to these problems for everyone?

Name___________________________________________________________

Address_________________________________________________________

City______________________________Zip___________________________

Phone___________________________________________________________

Thank You