Community Needs Assessment Survey

Community Members Survey

Question Title

* 1. Community Needs/Services: Of the list of services below, chose five (5) that you think are most needed in the community.

Energy Services

Employment Services

Nutrition Services

Education Services

Housing Services

Transportation Services

Self-Sufficiency Services

Health Care Services

Child Care Services

Emergency Services

Income Management Services

Housing Repair Services

Information and Referral Services

Parenting Services

Elderly Services

Early Childhood (Preschool) Services

Other (please specify)

Question Title

* 2. Community Problems/Barriers: Of the problems listed below, chose five (5) that you feel are the most serious to your community.

Drug/Alcohol Abuse

Crime/Public Safety

Homelessness

Domestic Violence (Abuse)

Unemployment

Hunger

Needs of the Elderly

Broken Homes

Lack of Education/Training

Lack of Adequate Paying Jobs

Lack of Affordable Child Care

Lack of Affordable Housing

Lack of Affordable Health Care

Lack of Affordable Transportation

Other (please specify)

Question Title

* 3. Age Range of Respondent. Please check one.

21 & under

22-35

36-54

55-61

62 & older

Question Title

* 4. Total Number of Individuals in household (including yourself)

One

Two

Three

Four

Five

Six or more

Question Title

* 5. Number of Children in the Household Under the Age of 18

zero

One

Two

Three

Four or more

Question Title

* 6. Household Monthly Income

$499 and under

$500-699

$700-899

$900-1199

$1200 and over