Community Needs Survey FY2020 Question Title * 1. Provide the following information Name City/Town ZIP/Postal Code OK Question Title * 2. What is your age? 20-30 31-40 41-50 51-60 61-70 71 and older OK Question Title * 3. What is your race? African American White Hispanic Asian Other OK Question Title * 4. What is your gender? Male Female OK Question Title * 5. How many people live in your household? One Two Three Four Five Six or More OK Question Title * 6. What is your housing status? Own Rent OK Question Title * 7. What is your martial status? Single Married Divorced Widow OK Question Title * 8. What is your source of income? (Check all that apply) Wages - full time Wages - part time Self employed Unemployed Pension Social Security SSI Child Support SNAP TANF OK Question Title * 9. What is your annual income? $1000 - $7999 $8000 - $15,999 $16,000 - $25,999 $26,000 - $35,999 $36,000 - $45,999 $46,000 or more OK Question Title * 10. How far did you go in school? 8th grade High School Diploma GED Trade School Some College Associate's Degree Bachelor's Degree Master's Degree OK Question Title * 11. Would you like help with these job related activities? (Check all that apply) Job Interviewing Resume' Writing Computer Training Dress for Success Job Placement Career /Job Training OK Question Title * 12. What services do you need from FACAA? (Check all that apply) Utility Assistance Mortgage or Rent Assistance Food Assistance GED Preparation Returning Citizen Vision Screening Financial Management Home Repairs (Weatherization Referral) OK Question Title * 13. What are the greatest needs in your community? (Check all that apply) Police Patrol Affordable Housing Parenting Programs Senior Activities Grocery Stores Better Schools Better Jobs Youth Programs OK Question Title * 14. Do you have Health Insurance? Yes No OK Question Title * 15. Who is your Health Insurance Provider? (Check all that apply) Medicaid Medicare Employer OK Question Title * 16. Are you a veteran? Yes No OK Question Title * 17. Are you receiving veteran benefits? Yes No OK Question Title * 18. Are you a registered voter? Yes No OK Question Title * 19. Overall, how satisfied or dissatisfied are you with our service? Very satisfied Satisfied Somewhat Dissatisfied Very Dissatisfied OK Question Title * 20. If dissatisfied, please state the reason why. OK DONE
