Community Needs Assessment Survey - Customer/Community/Client/Staff

Tri-County Community Action Agency, Inc. (TCCAA) is performing our triennial Community Needs Assessment. Please help us by filling out our quick survey.

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* 1. Which best describes you and your relationship with Tri-County Community Agency, Inc.?

Community Member

Customer/Client

Head Start Parent

Staff

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* 2. What county do you live in?

Harrison

Jasper

Newton

Panola

Sabine

San Augustine

Shelby

Tyler

Upshur

Angelina

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* 3. What is your age

18-24

25-34

35-44

45-54

55-64

65+

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* 4. What is your gender

Male

Female

Transgender

Prefer Not To Disclose

Other (please specify)

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* 5. What is your education level?

8th Grade or Less

Some High School

High School Diploma/GED

Technical or Occupational Certificate

Some College

Associates's Degree

Bachelor's Degree or Higher

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* 6. What is your race?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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* 7. What Language is spoken in your household? If "Other", please provide what language is spoken.

English

Spanish

Vietnamese

Other (please specify)

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* 8. What is your family situation?

Single Person

Two Adults - No Children

Single Parent

Two Parent Household

Non-Related Adults with Children

Multigenerational Household

Other (please specify)

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* 9. Please indicate the number of people living in your home

Other (please specify)

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* 10. Please indicate the total gross income for your entire household

$12,880 - $17,419

$17,420 - $21,959

$21,960 - $31,030

$31,040 - $40,119

$40,120 - $44,659

$44,660 - $49,199

$49,200 or more

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* 11. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

Migrant Seasonal Worker

Self-Employed

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* 12. How many minor children, by age, are currently live in your household?

	0	1	2	3	4	5	6	7	N/A
12 years old	12 years old 0	12 years old 1	12 years old 2	12 years old 3	12 years old 4	12 years old 5	12 years old 6	12 years old 7	12 years old N/A
17 years old	17 years old 0	17 years old 1	17 years old 2	17 years old 3	17 years old 4	17 years old 5	17 years old 6	17 years old 7	17 years old N/A
6 years old	6 years old 0	6 years old 1	6 years old 2	6 years old 3	6 years old 4	6 years old 5	6 years old 6	6 years old 7	6 years old N/A
8 years old	8 years old 0	8 years old 1	8 years old 2	8 years old 3	8 years old 4	8 years old 5	8 years old 6	8 years old 7	8 years old N/A
10 years old	10 years old 0	10 years old 1	10 years old 2	10 years old 3	10 years old 4	10 years old 5	10 years old 6	10 years old 7	10 years old N/A
4 years old	4 years old 0	4 years old 1	4 years old 2	4 years old 3	4 years old 4	4 years old 5	4 years old 6	4 years old 7	4 years old N/A
11 years old	11 years old 0	11 years old 1	11 years old 2	11 years old 3	11 years old 4	11 years old 5	11 years old 6	11 years old 7	11 years old N/A
15 years old	15 years old 0	15 years old 1	15 years old 2	15 years old 3	15 years old 4	15 years old 5	15 years old 6	15 years old 7	15 years old N/A
5 years old	5 years old 0	5 years old 1	5 years old 2	5 years old 3	5 years old 4	5 years old 5	5 years old 6	5 years old 7	5 years old N/A
3 years old	3 years old 0	3 years old 1	3 years old 2	3 years old 3	3 years old 4	3 years old 5	3 years old 6	3 years old 7	3 years old N/A
14 years old	14 years old 0	14 years old 1	14 years old 2	14 years old 3	14 years old 4	14 years old 5	14 years old 6	14 years old 7	14 years old N/A
13 years old	13 years old 0	13 years old 1	13 years old 2	13 years old 3	13 years old 4	13 years old 5	13 years old 6	13 years old 7	13 years old N/A
16 years old	16 years old 0	16 years old 1	16 years old 2	16 years old 3	16 years old 4	16 years old 5	16 years old 6	16 years old 7	16 years old N/A
Less than 1 year old	Less than 1 year old 0	Less than 1 year old 1	Less than 1 year old 2	Less than 1 year old 3	Less than 1 year old 4	Less than 1 year old 5	Less than 1 year old 6	Less than 1 year old 7	Less than 1 year old N/A
2 years old	2 years old 0	2 years old 1	2 years old 2	2 years old 3	2 years old 4	2 years old 5	2 years old 6	2 years old 7	2 years old N/A
1 year old	1 year old 0	1 year old 1	1 year old 2	1 year old 3	1 year old 4	1 year old 5	1 year old 6	1 year old 7	1 year old N/A
9 years old	9 years old 0	9 years old 1	9 years old 2	9 years old 3	9 years old 4	9 years old 5	9 years old 6	9 years old 7	9 years old N/A
7 years old	7 years old 0	7 years old 1	7 years old 2	7 years old 3	7 years old 4	7 years old 5	7 years old 6	7 years old 7	7 years old N/A
None of the above	None of the above 0	None of the above 1	None of the above 2	None of the above 3	None of the above 4	None of the above 5	None of the above 6	None of the above 7	None of the above N/A

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* 13. What statement is true regarding your housing status?

Own

Rent

Staying with Friends/Relatives

Homeless

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* 14. Do you or anyone in your household have any of the following housing related needs? (Please select your top 5. With 5 being the most important to you and your household)

	Most Important	Somewhat Important	Important	Not as Important	Least Important	Not Imporant	N/A
Home Repairs	Home Repairs Most Important	Home Repairs Somewhat Important	Home Repairs Important	Home Repairs Not as Important	Home Repairs Least Important	Home Repairs Not Imporant	Home Repairs N/A
Housing Not Affordable	Housing Not Affordable Most Important	Housing Not Affordable Somewhat Important	Housing Not Affordable Important	Housing Not Affordable Not as Important	Housing Not Affordable Least Important	Housing Not Affordable Not Imporant	Housing Not Affordable N/A
Home Not Safe - Structure	Home Not Safe - Structure Most Important	Home Not Safe - Structure Somewhat Important	Home Not Safe - Structure Important	Home Not Safe - Structure Not as Important	Home Not Safe - Structure Least Important	Home Not Safe - Structure Not Imporant	Home Not Safe - Structure N/A
Need Handicap Accessibility	Need Handicap Accessibility Most Important	Need Handicap Accessibility Somewhat Important	Need Handicap Accessibility Important	Need Handicap Accessibility Not as Important	Need Handicap Accessibility Least Important	Need Handicap Accessibility Not Imporant	Need Handicap Accessibility N/A
Mortgage or Rent Assistance	Mortgage or Rent Assistance Most Important	Mortgage or Rent Assistance Somewhat Important	Mortgage or Rent Assistance Important	Mortgage or Rent Assistance Not as Important	Mortgage or Rent Assistance Least Important	Mortgage or Rent Assistance Not Imporant	Mortgage or Rent Assistance N/A
None of the above	None of the above Most Important	None of the above Somewhat Important	None of the above Important	None of the above Not as Important	None of the above Least Important	None of the above Not Imporant	None of the above N/A

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* 15. Do you or anyone in your household need any of the following assistance with transportation? (Please select your top 5. With 5 being the most important to you and your household)

	Most Important	Somewhat Important	Important	Not As Important	Least Important	Not Important	N/A
Assistance with Insurance	Assistance with Insurance Most Important	Assistance with Insurance Somewhat Important	Assistance with Insurance Important	Assistance with Insurance Not As Important	Assistance with Insurance Least Important	Assistance with Insurance Not Important	Assistance with Insurance N/A
Transportation with someone with a disability	Transportation with someone with a disability Most Important	Transportation with someone with a disability Somewhat Important	Transportation with someone with a disability Important	Transportation with someone with a disability Not As Important	Transportation with someone with a disability Least Important	Transportation with someone with a disability Not Important	Transportation with someone with a disability N/A
Auto Repairs	Auto Repairs Most Important	Auto Repairs Somewhat Important	Auto Repairs Important	Auto Repairs Not As Important	Auto Repairs Least Important	Auto Repairs Not Important	Auto Repairs N/A
Driver's License	Driver's License Most Important	Driver's License Somewhat Important	Driver's License Important	Driver's License Not As Important	Driver's License Least Important	Driver's License Not Important	Driver's License N/A
Transportation from someone for local area for travel	Transportation from someone for local area for travel Most Important	Transportation from someone for local area for travel Somewhat Important	Transportation from someone for local area for travel Important	Transportation from someone for local area for travel Not As Important	Transportation from someone for local area for travel Least Important	Transportation from someone for local area for travel Not Important	Transportation from someone for local area for travel N/A
In need of a vehicle	In need of a vehicle Most Important	In need of a vehicle Somewhat Important	In need of a vehicle Important	In need of a vehicle Not As Important	In need of a vehicle Least Important	In need of a vehicle Not Important	In need of a vehicle N/A
Vehicle Registration	Vehicle Registration Most Important	Vehicle Registration Somewhat Important	Vehicle Registration Important	Vehicle Registration Not As Important	Vehicle Registration Least Important	Vehicle Registration Not Important	Vehicle Registration N/A
Transportation from someone for out of town travel	Transportation from someone for out of town travel Most Important	Transportation from someone for out of town travel Somewhat Important	Transportation from someone for out of town travel Important	Transportation from someone for out of town travel Not As Important	Transportation from someone for out of town travel Least Important	Transportation from someone for out of town travel Not Important	Transportation from someone for out of town travel N/A

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* 16. Do you have reliable phone access

Yes

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* 17. Do you have access to the Internet?

Yes

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* 18. Please select what assistance you or anyone in your household receives. (Please select your top 5)

	Most Important	Somewhat Important	Important	Not As Important	Least Important	Not Important	N/A
CHIPS	CHIPS Most Important	CHIPS Somewhat Important	CHIPS Important	CHIPS Not As Important	CHIPS Least Important	CHIPS Not Important	CHIPS N/A
Medicaid	Medicaid Most Important	Medicaid Somewhat Important	Medicaid Important	Medicaid Not As Important	Medicaid Least Important	Medicaid Not Important	Medicaid N/A
Medicare	Medicare Most Important	Medicare Somewhat Important	Medicare Important	Medicare Not As Important	Medicare Least Important	Medicare Not Important	Medicare N/A
Housing Voucher (Section 8)	Housing Voucher (Section 8) Most Important	Housing Voucher (Section 8) Somewhat Important	Housing Voucher (Section 8) Important	Housing Voucher (Section 8) Not As Important	Housing Voucher (Section 8) Least Important	Housing Voucher (Section 8) Not Important	Housing Voucher (Section 8) N/A
SNAP (Food Stamps)	SNAP (Food Stamps) Most Important	SNAP (Food Stamps) Somewhat Important	SNAP (Food Stamps) Important	SNAP (Food Stamps) Not As Important	SNAP (Food Stamps) Least Important	SNAP (Food Stamps) Not Important	SNAP (Food Stamps) N/A
TANF	TANF Most Important	TANF Somewhat Important	TANF Important	TANF Not As Important	TANF Least Important	TANF Not Important	TANF N/A
WIC	WIC Most Important	WIC Somewhat Important	WIC Important	WIC Not As Important	WIC Least Important	WIC Not Important	WIC N/A
Utility Assistance	Utility Assistance Most Important	Utility Assistance Somewhat Important	Utility Assistance Important	Utility Assistance Not As Important	Utility Assistance Least Important	Utility Assistance Not Important	Utility Assistance N/A
Rental Assistance	Rental Assistance Most Important	Rental Assistance Somewhat Important	Rental Assistance Important	Rental Assistance Not As Important	Rental Assistance Least Important	Rental Assistance Not Important	Rental Assistance N/A

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* 19. Do you or anyone in your household need assistance in any of these areas? (Please select your top 5. With 5 being the most important to you and your household)

	Most Important	Somewhat Important	Important	Not As Important	Least Important	Not Important	N/A
Alcohol/Drug Abuse	Alcohol/Drug Abuse Most Important	Alcohol/Drug Abuse Somewhat Important	Alcohol/Drug Abuse Important	Alcohol/Drug Abuse Not As Important	Alcohol/Drug Abuse Least Important	Alcohol/Drug Abuse Not Important	Alcohol/Drug Abuse N/A
Anger Management	Anger Management Most Important	Anger Management Somewhat Important	Anger Management Important	Anger Management Not As Important	Anger Management Least Important	Anger Management Not Important	Anger Management N/A
Caregiver Support	Caregiver Support Most Important	Caregiver Support Somewhat Important	Caregiver Support Important	Caregiver Support Not As Important	Caregiver Support Least Important	Caregiver Support Not Important	Caregiver Support N/A
Depression/Anxiety	Depression/Anxiety Most Important	Depression/Anxiety Somewhat Important	Depression/Anxiety Important	Depression/Anxiety Not As Important	Depression/Anxiety Least Important	Depression/Anxiety Not Important	Depression/Anxiety N/A
Disability Counseling	Disability Counseling Most Important	Disability Counseling Somewhat Important	Disability Counseling Important	Disability Counseling Not As Important	Disability Counseling Least Important	Disability Counseling Not Important	Disability Counseling N/A
Elder Abuse	Elder Abuse Most Important	Elder Abuse Somewhat Important	Elder Abuse Important	Elder Abuse Not As Important	Elder Abuse Least Important	Elder Abuse Not Important	Elder Abuse N/A
Parenting Classes	Parenting Classes Most Important	Parenting Classes Somewhat Important	Parenting Classes Important	Parenting Classes Not As Important	Parenting Classes Least Important	Parenting Classes Not Important	Parenting Classes N/A
Goal Setting	Goal Setting Most Important	Goal Setting Somewhat Important	Goal Setting Important	Goal Setting Not As Important	Goal Setting Least Important	Goal Setting Not Important	Goal Setting N/A
Mental Health/Behavioral Issues	Mental Health/Behavioral Issues Most Important	Mental Health/Behavioral Issues Somewhat Important	Mental Health/Behavioral Issues Important	Mental Health/Behavioral Issues Not As Important	Mental Health/Behavioral Issues Least Important	Mental Health/Behavioral Issues Not Important	Mental Health/Behavioral Issues N/A
Financial Money Management	Financial Money Management Most Important	Financial Money Management Somewhat Important	Financial Money Management Important	Financial Money Management Not As Important	Financial Money Management Least Important	Financial Money Management Not Important	Financial Money Management N/A
Domestic Violence Abuse (Adult or Child)	Domestic Violence Abuse (Adult or Child) Most Important	Domestic Violence Abuse (Adult or Child) Somewhat Important	Domestic Violence Abuse (Adult or Child) Important	Domestic Violence Abuse (Adult or Child) Not As Important	Domestic Violence Abuse (Adult or Child) Least Important	Domestic Violence Abuse (Adult or Child) Not Important	Domestic Violence Abuse (Adult or Child) N/A
Family Conflicts	Family Conflicts Most Important	Family Conflicts Somewhat Important	Family Conflicts Important	Family Conflicts Not As Important	Family Conflicts Least Important	Family Conflicts Not Important	Family Conflicts N/A
Thoughts of Suicide (in the past 6 months)	Thoughts of Suicide (in the past 6 months) Most Important	Thoughts of Suicide (in the past 6 months) Somewhat Important	Thoughts of Suicide (in the past 6 months) Important	Thoughts of Suicide (in the past 6 months) Not As Important	Thoughts of Suicide (in the past 6 months) Least Important	Thoughts of Suicide (in the past 6 months) Not Important	Thoughts of Suicide (in the past 6 months) N/A
Making Decisions/Problem Solving	Making Decisions/Problem Solving Most Important	Making Decisions/Problem Solving Somewhat Important	Making Decisions/Problem Solving Important	Making Decisions/Problem Solving Not As Important	Making Decisions/Problem Solving Least Important	Making Decisions/Problem Solving Not Important	Making Decisions/Problem Solving N/A
Additional Education	Additional Education Most Important	Additional Education Somewhat Important	Additional Education Important	Additional Education Not As Important	Additional Education Least Important	Additional Education Not Important	Additional Education N/A
Housing Assistance	Housing Assistance Most Important	Housing Assistance Somewhat Important	Housing Assistance Important	Housing Assistance Not As Important	Housing Assistance Least Important	Housing Assistance Not Important	Housing Assistance N/A
English as a Second Language (ESL)	English as a Second Language (ESL) Most Important	English as a Second Language (ESL) Somewhat Important	English as a Second Language (ESL) Important	English as a Second Language (ESL) Not As Important	English as a Second Language (ESL) Least Important	English as a Second Language (ESL) Not Important	English as a Second Language (ESL) N/A

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* 20. Do you or anyone in your household need help with these healthcare needs? (Please select your top 5. With 5 being the most important to you and your household)

	Most Important	Somewhat Important	Important	Not As Important	Least Important	Not Important	N/A
Adult with Disability	Adult with Disability Most Important	Adult with Disability Somewhat Important	Adult with Disability Important	Adult with Disability Not As Important	Adult with Disability Least Important	Adult with Disability Not Important	Adult with Disability N/A
AIDS/HIV Risk	AIDS/HIV Risk Most Important	AIDS/HIV Risk Somewhat Important	AIDS/HIV Risk Important	AIDS/HIV Risk Not As Important	AIDS/HIV Risk Least Important	AIDS/HIV Risk Not Important	AIDS/HIV Risk N/A
Child with Disability	Child with Disability Most Important	Child with Disability Somewhat Important	Child with Disability Important	Child with Disability Not As Important	Child with Disability Least Important	Child with Disability Not Important	Child with Disability N/A
Dental Care	Dental Care Most Important	Dental Care Somewhat Important	Dental Care Important	Dental Care Not As Important	Dental Care Least Important	Dental Care Not Important	Dental Care N/A
Diabetes	Diabetes Most Important	Diabetes Somewhat Important	Diabetes Important	Diabetes Not As Important	Diabetes Least Important	Diabetes Not Important	Diabetes N/A
Eye/Vision Care	Eye/Vision Care Most Important	Eye/Vision Care Somewhat Important	Eye/Vision Care Important	Eye/Vision Care Not As Important	Eye/Vision Care Least Important	Eye/Vision Care Not Important	Eye/Vision Care N/A
General Medical Care	General Medical Care Most Important	General Medical Care Somewhat Important	General Medical Care Important	General Medical Care Not As Important	General Medical Care Least Important	General Medical Care Not Important	General Medical Care N/A
Hearing Aid Care	Hearing Aid Care Most Important	Hearing Aid Care Somewhat Important	Hearing Aid Care Important	Hearing Aid Care Not As Important	Hearing Aid Care Least Important	Hearing Aid Care Not Important	Hearing Aid Care N/A
Heart Disease	Heart Disease Most Important	Heart Disease Somewhat Important	Heart Disease Important	Heart Disease Not As Important	Heart Disease Least Important	Heart Disease Not Important	Heart Disease N/A
Hypertension (High Blood Pressure)	Hypertension (High Blood Pressure) Most Important	Hypertension (High Blood Pressure) Somewhat Important	Hypertension (High Blood Pressure) Important	Hypertension (High Blood Pressure) Not As Important	Hypertension (High Blood Pressure) Least Important	Hypertension (High Blood Pressure) Not Important	Hypertension (High Blood Pressure) N/A
Medical Equipment	Medical Equipment Most Important	Medical Equipment Somewhat Important	Medical Equipment Important	Medical Equipment Not As Important	Medical Equipment Least Important	Medical Equipment Not Important	Medical Equipment N/A
Mental Health Care	Mental Health Care Most Important	Mental Health Care Somewhat Important	Mental Health Care Important	Mental Health Care Not As Important	Mental Health Care Least Important	Mental Health Care Not Important	Mental Health Care N/A
Prescription Medication	Prescription Medication Most Important	Prescription Medication Somewhat Important	Prescription Medication Important	Prescription Medication Not As Important	Prescription Medication Least Important	Prescription Medication Not Important	Prescription Medication N/A
STDs (Sexually Transmitted Disease)	STDs (Sexually Transmitted Disease) Most Important	STDs (Sexually Transmitted Disease) Somewhat Important	STDs (Sexually Transmitted Disease) Important	STDs (Sexually Transmitted Disease) Not As Important	STDs (Sexually Transmitted Disease) Least Important	STDs (Sexually Transmitted Disease) Not Important	STDs (Sexually Transmitted Disease) N/A
Substance Abuse Treatment	Substance Abuse Treatment Most Important	Substance Abuse Treatment Somewhat Important	Substance Abuse Treatment Important	Substance Abuse Treatment Not As Important	Substance Abuse Treatment Least Important	Substance Abuse Treatment Not Important	Substance Abuse Treatment N/A
Teen Pregnancy	Teen Pregnancy Most Important	Teen Pregnancy Somewhat Important	Teen Pregnancy Important	Teen Pregnancy Not As Important	Teen Pregnancy Least Important	Teen Pregnancy Not Important	Teen Pregnancy N/A
Transportation to Appointments	Transportation to Appointments Most Important	Transportation to Appointments Somewhat Important	Transportation to Appointments Important	Transportation to Appointments Not As Important	Transportation to Appointments Least Important	Transportation to Appointments Not Important	Transportation to Appointments N/A
None of the Above	None of the Above Most Important	None of the Above Somewhat Important	None of the Above Important	None of the Above Not As Important	None of the Above Least Important	None of the Above Not Important	None of the Above N/A

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* 21. Do you or anyone in your household have health insurance?

Yes

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* 22. Are you or anyone in your household a veteran?

Yes

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* 23. Do you or anyone in your household have any of these financial needs or problems? (Please select your top 5 of the highest needs for you or your household).

	High Need	Moderate Need	Somewhat Need	Don't Need
Earning a living wage	Earning a living wage High Need	Earning a living wage Moderate Need	Earning a living wage Somewhat Need	Earning a living wage Don't Need
Health Insurance	Health Insurance High Need	Health Insurance Moderate Need	Health Insurance Somewhat Need	Health Insurance Don't Need
Car Insurance	Car Insurance High Need	Car Insurance Moderate Need	Car Insurance Somewhat Need	Car Insurance Don't Need
Home/Renter's Insurance	Home/Renter's Insurance High Need	Home/Renter's Insurance Moderate Need	Home/Renter's Insurance Somewhat Need	Home/Renter's Insurance Don't Need
Assistance with collecting Child Support	Assistance with collecting Child Support High Need	Assistance with collecting Child Support Moderate Need	Assistance with collecting Child Support Somewhat Need	Assistance with collecting Child Support Don't Need
Financial Budgeting	Financial Budgeting High Need	Financial Budgeting Moderate Need	Financial Budgeting Somewhat Need	Financial Budgeting Don't Need
Improving Credit	Improving Credit High Need	Improving Credit Moderate Need	Improving Credit Somewhat Need	Improving Credit Don't Need

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* 24. Have you or anyone in your household been referred to any of these services in the past 12-months?

	Yes, the referral WAS helpful	Yes, but the referral WAS NOT helpful	Referral WAS NOT used	Resource was Unavailable	No - I've had no referral
Employment Assistance	Employment Assistance Yes, the referral WAS helpful	Employment Assistance Yes, but the referral WAS NOT helpful	Employment Assistance Referral WAS NOT used	Employment Assistance Resource was Unavailable	Employment Assistance No - I've had no referral
Educational Assistance	Educational Assistance Yes, the referral WAS helpful	Educational Assistance Yes, but the referral WAS NOT helpful	Educational Assistance Referral WAS NOT used	Educational Assistance Resource was Unavailable	Educational Assistance No - I've had no referral
Social/Emotional/Well-being	Social/Emotional/Well-being Yes, the referral WAS helpful	Social/Emotional/Well-being Yes, but the referral WAS NOT helpful	Social/Emotional/Well-being Referral WAS NOT used	Social/Emotional/Well-being Resource was Unavailable	Social/Emotional/Well-being No - I've had no referral
Childcare Assistance	Childcare Assistance Yes, the referral WAS helpful	Childcare Assistance Yes, but the referral WAS NOT helpful	Childcare Assistance Referral WAS NOT used	Childcare Assistance Resource was Unavailable	Childcare Assistance No - I've had no referral
Housing Assistance	Housing Assistance Yes, the referral WAS helpful	Housing Assistance Yes, but the referral WAS NOT helpful	Housing Assistance Referral WAS NOT used	Housing Assistance Resource was Unavailable	Housing Assistance No - I've had no referral
Financial Literacy	Financial Literacy Yes, the referral WAS helpful	Financial Literacy Yes, but the referral WAS NOT helpful	Financial Literacy Referral WAS NOT used	Financial Literacy Resource was Unavailable	Financial Literacy No - I've had no referral
Transportation Assistance	Transportation Assistance Yes, the referral WAS helpful	Transportation Assistance Yes, but the referral WAS NOT helpful	Transportation Assistance Referral WAS NOT used	Transportation Assistance Resource was Unavailable	Transportation Assistance No - I've had no referral
Nutrition Assistance	Nutrition Assistance Yes, the referral WAS helpful	Nutrition Assistance Yes, but the referral WAS NOT helpful	Nutrition Assistance Referral WAS NOT used	Nutrition Assistance Resource was Unavailable	Nutrition Assistance No - I've had no referral
Healthcare Assistance	Healthcare Assistance Yes, the referral WAS helpful	Healthcare Assistance Yes, but the referral WAS NOT helpful	Healthcare Assistance Referral WAS NOT used	Healthcare Assistance Resource was Unavailable	Healthcare Assistance No - I've had no referral
Head Start/Early Headstart	Head Start/Early Headstart Yes, the referral WAS helpful	Head Start/Early Headstart Yes, but the referral WAS NOT helpful	Head Start/Early Headstart Referral WAS NOT used	Head Start/Early Headstart Resource was Unavailable	Head Start/Early Headstart No - I've had no referral

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* 25. Are you or anyone in your household doing volunteer work? If so, please provide the typical volunteer schedule.

Yes

Other (please provide the typical volunteer schedule)

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* 26. What type of childcare (if any) are you currentl using other than Head Start/Early Head Start? (Choose all that apply)

Older Sibling

Relatives

Babysitter

Childcare Center

Licensed Family Childcare Center

None of the above

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* 27. What are the top 5 issues from the list below that you feel are major problems or concerns in your community? Please select your top 5 of the highest concerns/issues for you or your household).

	High Issue	Moderately High Issue	Somewhat High Issue	Not As Important of an Issue	Less of an Issue	Not an Issue	N/A
Lack of Affordable Housing	Lack of Affordable Housing High Issue	Lack of Affordable Housing Moderately High Issue	Lack of Affordable Housing Somewhat High Issue	Lack of Affordable Housing Not As Important of an Issue	Lack of Affordable Housing Less of an Issue	Lack of Affordable Housing Not an Issue	Lack of Affordable Housing N/A
Child Safety	Child Safety High Issue	Child Safety Moderately High Issue	Child Safety Somewhat High Issue	Child Safety Not As Important of an Issue	Child Safety Less of an Issue	Child Safety Not an Issue	Child Safety N/A
Lack of Affordable Childcare	Lack of Affordable Childcare High Issue	Lack of Affordable Childcare Moderately High Issue	Lack of Affordable Childcare Somewhat High Issue	Lack of Affordable Childcare Not As Important of an Issue	Lack of Affordable Childcare Less of an Issue	Lack of Affordable Childcare Not an Issue	Lack of Affordable Childcare N/A
Crime/Violence	Crime/Violence High Issue	Crime/Violence Moderately High Issue	Crime/Violence Somewhat High Issue	Crime/Violence Not As Important of an Issue	Crime/Violence Less of an Issue	Crime/Violence Not an Issue	Crime/Violence N/A
Domestic Violence	Domestic Violence High Issue	Domestic Violence Moderately High Issue	Domestic Violence Somewhat High Issue	Domestic Violence Not As Important of an Issue	Domestic Violence Less of an Issue	Domestic Violence Not an Issue	Domestic Violence N/A
Drug and Alcohol Abuse	Drug and Alcohol Abuse High Issue	Drug and Alcohol Abuse Moderately High Issue	Drug and Alcohol Abuse Somewhat High Issue	Drug and Alcohol Abuse Not As Important of an Issue	Drug and Alcohol Abuse Less of an Issue	Drug and Alcohol Abuse Not an Issue	Drug and Alcohol Abuse N/A
Lack of Services for Non-English Speaking Families	Lack of Services for Non-English Speaking Families High Issue	Lack of Services for Non-English Speaking Families Moderately High Issue	Lack of Services for Non-English Speaking Families Somewhat High Issue	Lack of Services for Non-English Speaking Families Not As Important of an Issue	Lack of Services for Non-English Speaking Families Less of an Issue	Lack of Services for Non-English Speaking Families Not an Issue	Lack of Services for Non-English Speaking Families N/A
Cost of Living Too High	Cost of Living Too High High Issue	Cost of Living Too High Moderately High Issue	Cost of Living Too High Somewhat High Issue	Cost of Living Too High Not As Important of an Issue	Cost of Living Too High Less of an Issue	Cost of Living Too High Not an Issue	Cost of Living Too High N/A
Gangs	Gangs High Issue	Gangs Moderately High Issue	Gangs Somewhat High Issue	Gangs Not As Important of an Issue	Gangs Less of an Issue	Gangs Not an Issue	Gangs N/A
Immigration/Citizenship	Immigration/Citizenship High Issue	Immigration/Citizenship Moderately High Issue	Immigration/Citizenship Somewhat High Issue	Immigration/Citizenship Not As Important of an Issue	Immigration/Citizenship Less of an Issue	Immigration/Citizenship Not an Issue	Immigration/Citizenship N/A
Health Problems	Health Problems High Issue	Health Problems Moderately High Issue	Health Problems Somewhat High Issue	Health Problems Not As Important of an Issue	Health Problems Less of an Issue	Health Problems Not an Issue	Health Problems N/A
Obesity	Obesity High Issue	Obesity Moderately High Issue	Obesity Somewhat High Issue	Obesity Not As Important of an Issue	Obesity Less of an Issue	Obesity Not an Issue	Obesity N/A
Child Nutrition	Child Nutrition High Issue	Child Nutrition Moderately High Issue	Child Nutrition Somewhat High Issue	Child Nutrition Not As Important of an Issue	Child Nutrition Less of an Issue	Child Nutrition Not an Issue	Child Nutrition N/A
Lack of Jobs	Lack of Jobs High Issue	Lack of Jobs Moderately High Issue	Lack of Jobs Somewhat High Issue	Lack of Jobs Not As Important of an Issue	Lack of Jobs Less of an Issue	Lack of Jobs Not an Issue	Lack of Jobs N/A
Transportation Issues	Transportation Issues High Issue	Transportation Issues Moderately High Issue	Transportation Issues Somewhat High Issue	Transportation Issues Not As Important of an Issue	Transportation Issues Less of an Issue	Transportation Issues Not an Issue	Transportation Issues N/A
Lack of Affordable Healthcare	Lack of Affordable Healthcare High Issue	Lack of Affordable Healthcare Moderately High Issue	Lack of Affordable Healthcare Somewhat High Issue	Lack of Affordable Healthcare Not As Important of an Issue	Lack of Affordable Healthcare Less of an Issue	Lack of Affordable Healthcare Not an Issue	Lack of Affordable Healthcare N/A
Difficulty getting needed services or resources	Difficulty getting needed services or resources High Issue	Difficulty getting needed services or resources Moderately High Issue	Difficulty getting needed services or resources Somewhat High Issue	Difficulty getting needed services or resources Not As Important of an Issue	Difficulty getting needed services or resources Less of an Issue	Difficulty getting needed services or resources Not an Issue	Difficulty getting needed services or resources N/A
Access to Personal Protection Equipment (PPE)	Access to Personal Protection Equipment (PPE) High Issue	Access to Personal Protection Equipment (PPE) Moderately High Issue	Access to Personal Protection Equipment (PPE) Somewhat High Issue	Access to Personal Protection Equipment (PPE) Not As Important of an Issue	Access to Personal Protection Equipment (PPE) Less of an Issue	Access to Personal Protection Equipment (PPE) Not an Issue	Access to Personal Protection Equipment (PPE) N/A
Unemployment/Furlough	Unemployment/Furlough High Issue	Unemployment/Furlough Moderately High Issue	Unemployment/Furlough Somewhat High Issue	Unemployment/Furlough Not As Important of an Issue	Unemployment/Furlough Less of an Issue	Unemployment/Furlough Not an Issue	Unemployment/Furlough N/A
Foreclosure/Eviction	Foreclosure/Eviction High Issue	Foreclosure/Eviction Moderately High Issue	Foreclosure/Eviction Somewhat High Issue	Foreclosure/Eviction Not As Important of an Issue	Foreclosure/Eviction Less of an Issue	Foreclosure/Eviction Not an Issue	Foreclosure/Eviction N/A
Loss of Health Insurance Coverage	Loss of Health Insurance Coverage High Issue	Loss of Health Insurance Coverage Moderately High Issue	Loss of Health Insurance Coverage Somewhat High Issue	Loss of Health Insurance Coverage Not As Important of an Issue	Loss of Health Insurance Coverage Less of an Issue	Loss of Health Insurance Coverage Not an Issue	Loss of Health Insurance Coverage N/A