CAANE Individual Needs Assessment Question Title * 1. What county do you live in? Name: City/Town: ZIP: Blount Cherokee DeKalb Jackson Marshall St. Clair Question Title * 2. What is your gender? Female Male Question Title * 3. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Question Title * 4. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race? White Black or African-American American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander From multiple races Question Title * 5. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group? I am not Spanish, Hispanic, or Latino Mexican Mexican-American Chicano Puerto Rican Cuban Cuban-American Some other Spanish, Hispanic, or Latino group From multiple Spanish, Hispanic, or Latino groups Question Title * 6. What is the highest level of education you have completed? Question Title * 7. Do you currently have health insurance, or not? Yes, I do No, I do not Question Title * 8. How many people currently live in your household? Question Title * 9. Do you rent or own the place you live? Rent Own Question Title * 10. Are you employed? Yes No Question Title * 11. Please list your top 5 family basic needs/concerns: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Public Transportation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Affordable Dental Care 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Affordable Health Insurance 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Affordable Childcare Facilities 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Financal Management 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Area Food Banks 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Educational Services for Children (tutoring, etc.) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Utility Assistance 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Affordable Prescription Drugs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Food 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Educational Services for Adults (GED, etc.) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Teen Pregnancy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Employment 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Child Care (preschool and after-school) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Affordable Housing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Youth Activities/Programs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Clothing 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Affordable Mortgages 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Transportation/Gas 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Crimes-Violence and Drugs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Job Training Next