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Community Needs Assessment Survey
Community Members Survey
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)
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)
3.
Age Range of Respondent. Please check one.
21 & under
22-35
36-54
55-61
62 & older
4.
Total Number of Individuals in household (including yourself)
One
Two
Three
Four
Five
Six or more
5.
Number of Children in the Household Under the Age of 18
zero
One
Two
Three
Four or more
6.
Household Monthly Income
$499 and under
$500-699
$700-899
$900-1199
$1200 and over
Current Progress,
0 of 6 answered