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Community Needs Survey -Housing
Please answer the following questions truthfully. Your answers will help us improve health services in our community. All responses are confidential.
1.
Age
Under 18
18-24
25-34
35-44
45-54
55-64
65+
2.
Race/ Ethnicity
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Another race
3.
What is your total monthly household income?
$0 - $500
$501 - $1,000
$1,001 - $2,000
$2,001 - $3,000
$3,001 - $4,000
$4,001 and above
4.
Gender
Male
Female
Non-Binary
Prefer not to answer
Prefer to self-describe
5.
How much do you pay per month for housing? (rent/ mortgage)
$0-$ 500
$501- $800
$801-$1,000
$1,001 - $1,300
More than $1,300
6.
What type of housing do you currently live in?
Apartment
Single-family home
Mobile home
Transitional Housing
Motel/ Hotel
Vehicle
Emergency Shelter
Outside/ Encampment
Other (please specify)
7.
Are you or someone in your family homeless or close to losing housing?
Yes, homeless now
Yes, close to losing housing
No
8.
How long have you been in your current housing situation?
Less than a month
1-3 months
4-11 months
1 year or more
9.
Including yourself, are there children, seniors, or people with disabilities in your household?
Children (under 18)
Seniors (over 60)
People with physical disabilities
People with mental health conditions
None of the above
10.
Do you currently get any housing help like section 8, emergency rental aid, transitional housing, etc?
Yes
No
I applied but haven't been approved yet.
11.
Have you ever tried to get housing help?
Yes
No
12.
If yes, what made it hard?
Long waitlists
No housing available
The applications are hard to fill out
I didn't qualify for help
I don't know where to go ask for help
Trouble getting in touch with landlords/ rental places
I haven't tried to get help
13.
What kind of housing help do you think is needed most in our area?
A shelter to stay in
Transitional housing
A low-cost place to rent
Help paying rent or utilities
Help finding a home
Help with a deposit
14.
What is the biggest challenge to finding or keeping housing? (Select all that apply)
No affordable rentals
I have been evicted before
Bad credit
I have been to jail
Mental health/ substance (drug/ alcohol) use
No car
I don't make enough money/ I have no job.
15.
Do you feel safe where you live?
Yes
No
Sometimes
16.
I would like to be entered into a raffle for a $50 gift card.
Yes
No
Name/ Phone number
17.
I would like to be contacted for help with housing.
Yes
No
Name/ Phone Number
