2009 Council for Economic Opportunities in Greater Cleveland Community Assessment Survey (CSBG)

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!

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)

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) Adult literacy or GED classes

Child Care

Debt Collection/Bankruptcy Services

Education/Scholarship Services

Ex-Offender/Re-Entry Services

Extra Food/Hot Meals

Food Stamps

Health Care Services

Help Getting to School or Work

Help Paying Utilities, Rent or Mortgage

Housing Search Assistance

Individual or Family Counseling

Information About Starting a Business

Job Search Assistance

Parenting Education

TANF/Ohio Works First

Work Skills Training

Other

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

What stops you from using any needed services? (CHECK ALL THAT APPLY) Lack of child/day care

Services cost too much money

Lack of transportation

Services not available in or near your community

Services not offered at good times

Waiting lists

Finding out you do not qualify for services

Other

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

What is most important to you when choosing an agency for service? (CHOOSE TWO) It's within walking distance of where you live

It's near your job/training or education program

It's near a bus route

Transportation to agency is provided

Other

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

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

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

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

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

What type of child care arrangement(s)would best meet the needs of you and your child? (CHECK ALL THAT APPLY) Part day care for infants age 0-2

Fully day care for infants age 0-2

Part day care for toddlers age 3-5

Full day care for toddlers age 3-5

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

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

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

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

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

If yes, which type of care do they need? (CHOOS ONE) Before care

After Care

Both

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

What are the TOP THREE ways you learn about available services? (CHOOSE THREE) Ads on Public Transportation

Child's School

Community Agencies

Community Events

County Office/Agency

Health Care Office (ex. Doctor or Dentist)

Library

Newspaper/Magazines

Radio

Television

Relative/Friend

Social Worker

Other

11. What is your gender (sex)?

What is your gender (sex)? Female

Male

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

What is your ethnic group (race)? (CHECK ONE) Black/African American

American Indian

Alaska Native

Asian

Caucasian/White

Hispanic/Latino

Native Hawaiian/Pacific Islander

Multi-race (any 2 or more)

Other (please specify)

13. What language is spoken in your home?

What language is spoken in your home? English

Spanish

Arabic

Other

14. Which best describes your marital status?

Which best describes your marital status? Single

Married

Separated

Divorced

Widowed

15. What is your age?

What is your age? Under 18

18-24

25-34

35-44

45-54

55-64

65 and above

16. How many people live in your home?

How many people live in your home? 1

17. How many children live in your home?

How many children live in your home? 0

4 or more

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

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

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

If yes, is your foster child age 15 or older? Yes

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

What is the highest level of education you have completed? (CHECK ONE) Did not graduate from high school

Earned high school diploma or GED

Completed 1-2 years college or technical school

Earned Associate degree or technical certificate

Two year college degree or certificate

Completed 3-4 years college or technical school

Earned Bachelor's degree

Earned Master's degree or higher

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

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

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

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

Job training and placement

Medical and dental care

Other

23. Are you currently employed? (CHECK ONE)

Are you currently employed? (CHECK ONE) Yes, full-time

Yes, part-time

Yes, seasonal

Yes, working training

Yes, other

No, unemployed

No, student

No, homemaker

No, retired

No, other

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

Besides income from employment, what other types of income do you receive? (CHECK ALL THAT APPLY) TANF/Welfare

Social Security

Disability

Child Support

Medicaid

Food Stamps

Pension

Housing Subsidy

None

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

What is your household's gross annual income? (CHECK ONE) $0-$10,830

$10,831-$21,660

$21,661-$29,140

$29,141-$36,620

$36,621-$44,100

$44,101-$51,580

$51,581 and up

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

How would you describe your housing situation? (CHECK ONE) Homeless

Living with relatives or friends

Living in a temporary shelter

Renting a subsidized home or apartment

Renting an unsubsidized home, apartment or condo

Buying home, in foreclosure

Buying home, more than 1 month behind on payments

Buying home, payments caught up

Co-op home ownership (government program)

Own home outright, no mortgage

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

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

28. If yes, do you have internet access?

If yes, do you have internet access? Yes

29. What is your zip code

What is your zip code

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

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

Glenville NOC

HEAP

Hough NOC

Mt. Pleasant NOC

Tremont NOC

May Dugan

2009 Council for Economic Opportunities in Greater Cleveland Community Assessment Survey (CSBG)Exit this survey >>

Community Assessment Survey

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)

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

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

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

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

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

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

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

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

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

11. What is your gender (sex)?

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

13. What language is spoken in your home?

14. Which best describes your marital status?

15. What is your age?

16. How many people live in your home?

17. How many children live in your home?

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

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

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

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

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

23. Are you currently employed? (CHECK ONE)

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

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

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

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

28. If yes, do you have internet access?

29. What is your zip code

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

2009 Council for Economic Opportunities in Greater Cleveland Community Assessment Survey (CSBG)
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