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.?

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* 2. What county do you live in?

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* 3. What is your age

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* 4. What is your gender

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* 5. What is your education level?

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* 6. What is your race?

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

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* 8. What is your family situation?

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

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

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

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

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

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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 Not Safe - Structure
Need Handicap Accessibility
Housing Not Affordable
Mortgage or Rent Assistance
None of the above

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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
Driver's License
Vehicle Registration
In need of a vehicle
Transportation from someone for local area for travel
Auto Repairs
Assistance with Insurance
Transportation with someone with a disability
Transportation from someone for out of town travel

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* 16. Do you have reliable phone access

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* 17. Do you have access to the Internet?

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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
Medicaid
Medicare
Housing Voucher (Section 8)
SNAP (Food Stamps)
TANF
WIC
Utility Assistance
Rental Assistance

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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
Anger Management
Caregiver Support
Depression/Anxiety
Disability Counseling
Elder Abuse
Parenting Classes
Goal Setting
Mental Health/Behavioral Issues
Financial Money Management
Domestic Violence Abuse (Adult or Child)
Family Conflicts
Thoughts of Suicide (in the past 6 months)
Making Decisions/Problem Solving
Additional Education
Housing Assistance
English as a Second Language (ESL)

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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
AIDS/HIV Risk
Child with Disability
Dental Care
Diabetes
Eye/Vision Care
General Medical Care
Hearing Aid Care