{"id":9582,"date":"2023-05-03T11:28:29","date_gmt":"2023-05-03T09:28:29","guid":{"rendered":"https:\/\/www.lausanneregion.ch\/?page_id=9582"},"modified":"2024-06-10T11:31:05","modified_gmt":"2024-06-10T09:31:05","slug":"questionnaire-danalyse-intercommunale-des-besoins-seniors","status":"publish","type":"page","link":"https:\/\/www.lausanneregion.ch\/seniors-intergenerations\/les-seniors\/questionnaire-danalyse-intercommunale-des-besoins-seniors\/","title":{"rendered":"Questionnaire d&rsquo;analyse communale des besoins seniors"},"content":{"rendered":"<div class=\"the-content\"><p>La Municipalit\u00e9 de Villars-Sainte-Croix a pris la d\u00e9cision d\u2019interroger sa population seniors sur ses envies et besoins.<\/p>\n<p>Le questionnaire pr\u00e9sent\u00e9 ci-dessous devrait \u00eatre compl\u00e9t\u00e9 en une dizaine de minutes.<\/p>\n<p>Nous vous remercions d&rsquo;avance pour votre participation.<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_78' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Questionnaire d'analyse communale des besoins des seniors<\/h2>\n                            <p class='gform_description'>Pour la commune de Villars-Sainte-Croix<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_78'  action='\/wp-json\/wp\/v2\/pages\/9582\/' data-formid='78' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_78' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_78_3\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_3\" ><h3 class=\"gsection_title\">Lieu d&#039;habitation<\/h3><\/div><div id=\"field_78_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_4\" ><label class='gfield_label gform-field-label' for='input_78_4'>1. Depuis combien de temps vivez-vous dans votre commune ?<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_78_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_6\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2.\tPour vous, existe-il un centre d\u00e9fini dans votre commune ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_6'><div class='gchoice gchoice_78_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Oui'  id='choice_78_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_6_1' id='label_78_6_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Non'  id='choice_78_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_6_2' id='label_78_6_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_5\" ><label class='gfield_label gform-field-label' for='input_78_5'>Si oui, lequel ou lesquels ?<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_78_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_8\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_8\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3.\tEnvisagez-vous de rester vivre dans votre commune ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_8'><div class='gchoice gchoice_78_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Oui'  id='choice_78_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_8_1' id='label_78_8_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_8_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.2' type='checkbox'  value='Non'  id='choice_78_8_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_8_2' id='label_78_8_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_7\" ><label class='gfield_label gform-field-label' for='input_78_7'>4.\tQu\u2019est-ce que vous appr\u00e9ciez dans votre commune ?<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_78_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_78_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_9\" ><label class='gfield_label gform-field-label' for='input_78_9'>5.\tQu\u2019est-ce qui pourrait \u00eatre am\u00e9lior\u00e9 dans votre commune ?<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_78_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_78_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_11\" ><h3 class=\"gsection_title\">Qualit\u00e9 de vie, espaces de rencontre et liens sociaux<\/h3><\/div><fieldset id=\"field_78_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >6.\tAvez-vous une personne sur qui compter en cas de besoin ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_10'><div class='gchoice gchoice_78_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Oui, de la famille\/entourage dans la commune'  id='choice_78_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_10_1' id='label_78_10_1' class='gform-field-label gform-field-label--type-inline'>Oui, de la famille\/entourage dans la commune<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Oui, de la famille\/entourage hors de la commune'  id='choice_78_10_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_10_2' id='label_78_10_2' class='gform-field-label gform-field-label--type-inline'>Oui, de la famille\/entourage hors de la commune<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='Oui, des connaissances\/voisins dans la commune'  id='choice_78_10_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_10_3' id='label_78_10_3' class='gform-field-label gform-field-label--type-inline'>Oui, des connaissances\/voisins dans la commune<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='Oui, des connaissances en dehors de la commune'  id='choice_78_10_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_10_4' id='label_78_10_4' class='gform-field-label gform-field-label--type-inline'>Oui, des connaissances en dehors de la commune<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_10_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.5' type='checkbox'  value='Oui, du personnel des Centres M\u00e9dico-Sociaux (CMS)'  id='choice_78_10_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_10_5' id='label_78_10_5' class='gform-field-label gform-field-label--type-inline'>Oui, du personnel des Centres M\u00e9dico-Sociaux (CMS)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_10_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.6' type='checkbox'  value='Non'  id='choice_78_10_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_10_6' id='label_78_10_6' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_12\" ><label class='gfield_label gform-field-label' for='input_78_12'>7.\tAuriez-vous des besoins particuliers (en mati\u00e8re de s\u00e9curit\u00e9, de logement, de mobilit\u00e9, de sant\u00e9, d\u2019information, etc.) ?<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_78_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_13\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >8.\t\u00cates-vous utilisateur ou utilisatrice des transports publics ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_13'><div class='gchoice gchoice_78_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Oui'  id='choice_78_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_13_1' id='label_78_13_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Non'  id='choice_78_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_13_2' id='label_78_13_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_49\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Si oui, \u00e0 quelle fr\u00e9quence ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_49'><div class='gchoice gchoice_78_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Jamais'  id='choice_78_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_49_1' id='label_78_49_1' class='gform-field-label gform-field-label--type-inline'>Jamais<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='De temps en temps'  id='choice_78_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_49_2' id='label_78_49_2' class='gform-field-label gform-field-label--type-inline'>De temps en temps<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='R\u00e9guli\u00e8rement'  id='choice_78_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_49_3' id='label_78_49_3' class='gform-field-label gform-field-label--type-inline'>R\u00e9guli\u00e8rement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='Tous les jours'  id='choice_78_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_49_4' id='label_78_49_4' class='gform-field-label gform-field-label--type-inline'>Tous les jours<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_48\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >9.\tPoss\u00e8dez-vous un permis de conduire ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_48'><div class='gchoice gchoice_78_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Oui'  id='choice_78_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_48_1' id='label_78_48_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='Non'  id='choice_78_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_48_2' id='label_78_48_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_50\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >10.\tSavez-vous o\u00f9 trouver de l\u2019information concernant les aides dont vous pourriez b\u00e9n\u00e9ficier ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_50'><div class='gchoice gchoice_78_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Oui'  id='choice_78_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_50_1' id='label_78_50_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Non'  id='choice_78_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_50_2' id='label_78_50_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_14\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_14\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Si non, pour quels types d\u2019aides d\u00e9sireriez-vous \u00eatre mieux inform\u00e9\u00b7e ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_14'><div class='gchoice gchoice_78_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Aides financi\u00e8res'  id='choice_78_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_14_1' id='label_78_14_1' class='gform-field-label gform-field-label--type-inline'>Aides financi\u00e8res<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='Aides et soins \u00e0 domicile'  id='choice_78_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_14_2' id='label_78_14_2' class='gform-field-label gform-field-label--type-inline'>Aides et soins \u00e0 domicile<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='En cas de solitude'  id='choice_78_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_14_3' id='label_78_14_3' class='gform-field-label gform-field-label--type-inline'>En cas de solitude<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='Outils num\u00e9riques'  id='choice_78_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_14_4' id='label_78_14_4' class='gform-field-label gform-field-label--type-inline'>Outils num\u00e9riques<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_30\" ><label class='gfield_label gform-field-label' for='input_78_30'>Autre :<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_78_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >11.\tApportez-vous de l\u2019aide r\u00e9guli\u00e8re \u00e0 quelqu\u2019un ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_16'><div class='gchoice gchoice_78_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Oui'  id='choice_78_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_16_1' id='label_78_16_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Non'  id='choice_78_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_16_2' id='label_78_16_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_18\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Si oui, \u00e0 quelle fr\u00e9quence ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_18'><div class='gchoice gchoice_78_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Plusieurs fois par mois'  id='choice_78_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_18_1' id='label_78_18_1' class='gform-field-label gform-field-label--type-inline'>Plusieurs fois par mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='1 \u00e0 2 jours par semaine'  id='choice_78_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_18_2' id='label_78_18_2' class='gform-field-label gform-field-label--type-inline'>1 \u00e0 2 jours par semaine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='Plus de 2 jours par semaine'  id='choice_78_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_18_3' id='label_78_18_3' class='gform-field-label gform-field-label--type-inline'>Plus de 2 jours par semaine<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_19\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Si oui, quelle charge repr\u00e9sente cette aide r\u00e9guli\u00e8re pour vous ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_19'><div class='gchoice gchoice_78_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Faible'  id='choice_78_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_19_1' id='label_78_19_1' class='gform-field-label gform-field-label--type-inline'>Faible<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Moyenne'  id='choice_78_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_19_2' id='label_78_19_2' class='gform-field-label gform-field-label--type-inline'>Moyenne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Forte'  id='choice_78_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_19_3' id='label_78_19_3' class='gform-field-label gform-field-label--type-inline'>Forte<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Tr\u00e8s forte'  id='choice_78_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_19_4' id='label_78_19_4' class='gform-field-label gform-field-label--type-inline'>Tr\u00e8s forte<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_20\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >12. Y a-t-il des moments o\u00f9 vous vous sentez seul(e) ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_20'><div class='gchoice gchoice_78_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Jamais'  id='choice_78_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_20_1' id='label_78_20_1' class='gform-field-label gform-field-label--type-inline'>Jamais<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='De temps en temps'  id='choice_78_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_20_2' id='label_78_20_2' class='gform-field-label gform-field-label--type-inline'>De temps en temps<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='R\u00e9guli\u00e8rement'  id='choice_78_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_20_3' id='label_78_20_3' class='gform-field-label gform-field-label--type-inline'>R\u00e9guli\u00e8rement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Tous les jours'  id='choice_78_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_20_4' id='label_78_20_4' class='gform-field-label gform-field-label--type-inline'>Tous les jours<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_58\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_58\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >13. Seriez-vous int\u00e9ress\u00e9(e) si la commune poss\u00e9dait des logements prot\u00e9g\u00e9s ? (sans engagement)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_58'><div class='gchoice gchoice_78_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Oui'  id='choice_78_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_58_1' id='label_78_58_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Non'  id='choice_78_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_58_2' id='label_78_58_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_59\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >14. Y a-t-il des leiux de rencontre dans votre commune ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_59'><div class='gchoice gchoice_78_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Oui'  id='choice_78_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_59_1' id='label_78_59_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Non'  id='choice_78_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_59_2' id='label_78_59_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_60\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Si oui, est-ce que vous les fr\u00e9quentez ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_60'><div class='gchoice gchoice_78_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Oui'  id='choice_78_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_60_1' id='label_78_60_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Non'  id='choice_78_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_60_2' id='label_78_60_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_61\" ><label class='gfield_label gform-field-label' for='input_78_61'>Si non, que souhaiteriez-vous comme lieu de rencontre ?<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_78_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_23\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >15.\t\u00cates-vous membre d\u2019une association ou d\u2019un groupe actif (club de lecture, cercle des loisirs, activit\u00e9 sportive, activit\u00e9s de Pro Senectute ou AVIVO, etc.) dans votre commune ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_23'><div class='gchoice gchoice_78_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Oui'  id='choice_78_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_23_1' id='label_78_23_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Non'  id='choice_78_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_23_2' id='label_78_23_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_24\" ><label class='gfield_label gform-field-label' for='input_78_24'>Si oui, lequel ou lesquels ?<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_78_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_25\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Et en dehors de votre commune ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_25'><div class='gchoice gchoice_78_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Oui'  id='choice_78_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_25_1' id='label_78_25_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Non'  id='choice_78_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_25_2' id='label_78_25_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_26\" ><label class='gfield_label gform-field-label' for='input_78_26'>Si oui, lequel ou lesquels ?<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_78_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >16.\tParticipez-vous aux \u00e9v\u00e9nements organis\u00e9s \u00e0 votre intention par votre commune ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_27'><div class='gchoice gchoice_78_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Oui'  id='choice_78_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_27_1' id='label_78_27_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Non'  id='choice_78_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_27_2' id='label_78_27_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_28\" ><label class='gfield_label gform-field-label' for='input_78_28'>Si oui, lequel ou lesquels ?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_78_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_29\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >17.\tSouhaiteriez-vous vous engager dans des actions dans l\u2019un de ces domaines ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_29'><div class='gchoice gchoice_78_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Interg\u00e9n\u00e9rationnel'  id='choice_78_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_29_1' id='label_78_29_1' class='gform-field-label gform-field-label--type-inline'>Interg\u00e9n\u00e9rationnel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Activit\u00e9s sportives'  id='choice_78_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_29_2' id='label_78_29_2' class='gform-field-label gform-field-label--type-inline'>Activit\u00e9s sportives<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Entraide'  id='choice_78_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_29_3' id='label_78_29_3' class='gform-field-label gform-field-label--type-inline'>Entraide<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Environnement'  id='choice_78_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_29_4' id='label_78_29_4' class='gform-field-label gform-field-label--type-inline'>Environnement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.5' type='checkbox'  value='Rencontre et liens sociaux (par ex. caf\u00e9-croissant)'  id='choice_78_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_29_5' id='label_78_29_5' class='gform-field-label gform-field-label--type-inline'>Rencontre et liens sociaux (par ex. caf\u00e9-croissant)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_31\" ><label class='gfield_label gform-field-label' for='input_78_31'>Autre :<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_78_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_78_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_32\" ><label class='gfield_label gform-field-label' for='input_78_32'>Auriez-vous des id\u00e9es d\u2019actions dans l\u2019un des domaines ci-dessus ?<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_78_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_33\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >18.\tSi de nouvelles activit\u00e9s ou \u00e9v\u00e9nements \u00e9taient organis\u00e9s dans votre commune, souhaiteriez-vous y participer ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_33'><div class='gchoice gchoice_78_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Oui'  id='choice_78_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_33_1' id='label_78_33_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Non'  id='choice_78_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_33_2' id='label_78_33_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_51\" ><label class='gfield_label gform-field-label' for='input_78_51'>Si oui, quelles activit\u00e9s ou infrastructures d\u00e9sireriez-vous ?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_78_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_34\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >19.\tSi des offres d\u2019activit\u00e9s vous \u00e9taient propos\u00e9es dans des communes voisines, seriez-vous d\u2019accord de vous d\u00e9placer pour y participer ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_34'><div class='gchoice gchoice_78_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Oui'  id='choice_78_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_34_1' id='label_78_34_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Non'  id='choice_78_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_34_2' id='label_78_34_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_46\" ><label class='gfield_label gform-field-label' for='input_78_46'>Si oui, dans quelles communes seriez-vous pr\u00eate ou pr\u00eat \u00e0 vous d\u00e9placer ?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_78_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_35\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >20.\tAvez-vous contact avec des personnes des communes voisines de la v\u00f4tre ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_35'><div class='gchoice gchoice_78_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Oui'  id='choice_78_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_35_1' id='label_78_35_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Non'  id='choice_78_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_35_2' id='label_78_35_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_36\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >21.\tRencontrez-vous des difficult\u00e9s relatives au ramassage des d\u00e9chets dans votre commune ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_36'><div class='gchoice gchoice_78_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Oui'  id='choice_78_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_36_1' id='label_78_36_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Non'  id='choice_78_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_36_2' id='label_78_36_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_37\" ><label class='gfield_label gform-field-label' for='input_78_37'>Si oui, quels types de difficult\u00e9s ?<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_78_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_78_62\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_62\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >22.\tPensez-vous avoir besoin d&#039;un soutien, de conseil concernant les outils num\u00e9riques<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_62'><div class='gchoice gchoice_78_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='Oui'  id='choice_78_62_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_62_1' id='label_78_62_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='Non'  id='choice_78_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_62_2' id='label_78_62_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_38\" ><h3 class=\"gsection_title\">Donn\u00e9es personnelles<\/h3><\/div><div id=\"field_78_40\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_40\" ><label class='gfield_label gform-field-label' for='input_78_40'>Vous \u00eates<\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_78_40' class='large gfield_select'     aria-invalid=\"false\" ><option value='Une femme' >Une femme<\/option><option value='Un homme' >Un homme<\/option><\/select><\/div><\/div><div id=\"field_78_41\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_41\" ><label class='gfield_label gform-field-label' for='input_78_41'>Ann\u00e9e de naissance<\/label><div class='ginput_container ginput_container_number'><input name='input_41' id='input_78_41' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_78_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_43\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Vous vivez<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_43'><div class='gchoice gchoice_78_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Seul(e)'  id='choice_78_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_43_1' id='label_78_43_1' class='gform-field-label gform-field-label--type-inline'>Seul(e)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='En couple'  id='choice_78_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_43_2' id='label_78_43_2' class='gform-field-label gform-field-label--type-inline'>En couple<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='En famille'  id='choice_78_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_43_3' id='label_78_43_3' class='gform-field-label gform-field-label--type-inline'>En famille<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_78_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_44\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00cates-vous encore actif ou active professionnellement ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_78_44'><div class='gchoice gchoice_78_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Oui'  id='choice_78_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_44_1' id='label_78_44_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_78_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='Non'  id='choice_78_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_44_2' id='label_78_44_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_78_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_45\" ><label class='gfield_label gform-field-label' for='input_78_45'>Avez-vous d&#039;autres commentaires ?<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_78_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_78_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_54\" ><h3 class=\"gsection_title\">\u00cates-vous d&#039;accord d&#039;\u00eatre contact\u00e9(e) personnellement pour approfondir ce sondage ou participer \u00e0 un groupe de travail ? Si oui, merci de compl\u00e9ter les donn\u00e9es ci-dessous :<\/h3><\/div><div id=\"field_78_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_52\" ><label class='gfield_label gform-field-label' for='input_78_52'>Nom<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_78_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_78_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_55\" ><label class='gfield_label gform-field-label' for='input_78_55'>Pr\u00e9nom<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_78_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_78_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_57\" ><label class='gfield_label gform-field-label' for='input_78_57'>T\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_78_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_78_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_78_56\" ><label class='gfield_label gform-field-label' for='input_78_56'>E-Mail<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_78_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_78' class='gform_button button' value='Envoyer'  onclick='if(window[\"gf_submitting_78\"]){return false;}  if( !jQuery(\"#gform_78\")[0].checkValidity || jQuery(\"#gform_78\")[0].checkValidity()){window[\"gf_submitting_78\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_78\"]){return false;} if( !jQuery(\"#gform_78\")[0].checkValidity || jQuery(\"#gform_78\")[0].checkValidity()){window[\"gf_submitting_78\"]=true;}  jQuery(\"#gform_78\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_78' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='78' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_78' 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