Community Assessment Survey

Your answers to the following questions will help us to better serve our community. Please take a few minutes to answer each question. There are no right or wrong answers. Please complete both sides of the page. You do not need to put your name on this form. Your opinion is important to us. Thank You!

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* 1. In the past 12 months, which of the following services do you think you or your family NEEDED BUT WERE NOT ABLE TO FIND OR RECEIVE? (CHECK ALL THAT APPLY)

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* 2. What stops you from using any needed services? (CHECK ALL THAT APPLY)

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* 3. What is most important to you when choosing an agency for service? (CHOOSE TWO)

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* 4. Do you have any children age 0-4 years old? If no, SKIP to 7.

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* 5. Are you in need of child care for your children age 0-4? If no, SKIP to 7.

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* 6. What type of child care arrangement(s)would best meet the needs of you and your child? (CHECK ALL THAT APPLY)

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* 7. Do you have children age 5 and up? If no, SKIP TO 10.

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* 8. If yes, do they need care before or after school? If no SKIP to 10.

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* 9. If yes, which type of care do they need? (CHOOS ONE)

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* 10. What are the TOP THREE ways you learn about available services? (CHOOSE THREE)

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* 11. What is your gender (sex)?

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* 12. What is your ethnic group (race)? (CHECK ONE)

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* 13. What language is spoken in your home?

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* 14. Which best describes your marital status?

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* 15. What is your age?

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* 16. How many people live in your home?

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* 17. How many children live in your home?

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* 18. Are you a foster parent? If no SKIP to 20.

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* 19. If yes, is your foster child age 15 or older?

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* 20. What is the highest level of education you have completed? (CHECK ONE)

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* 21. Are you an ex-offender? If no SKIP TO 23.

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* 22. If yes, do you need any of the following types of assistance? (CHECK ALL THAT APPLY)

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* 23. Are you currently employed? (CHECK ONE)

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* 24. Besides income from employment, what other types of income do you receive? (CHECK ALL THAT APPLY)

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* 25. What is your household's gross annual income? (CHECK ONE)

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* 26. How would you describe your housing situation? (CHECK ONE)

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* 27. Is there a computer in your home? If no, skip to question 29.

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* 28. If yes, do you have internet access?

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* 29. What is your zip code

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* 30. Which CEOGC site does this customer receive services? (To be answered by CEOGC staff entering data into Survey Monkey)

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