Exit
 
 100% of survey complete.
BROC Community Action  is collecting responses to the following Community Needs Assessment to ensure that we offer the best possible programs and services for those living throughout Rutland and Bennington Counties. We value your time in filling out this survey. 

This survey can be anonymous or if you provide us with your name and a way to contact you, you will be entered in a drawing for a gift card!  

Question Title

* 1. The list below includes needs that are basic to everyone's health and well-being. Over the past twelve (12) months, which services have you sought help for? (check all that apply)

Question Title

* 2. What services do you utilize most frequently?

Question Title

* 3. Please indicate which, if any, of the following sources you are currently using to meet each of the needs listed below.

  Yourself Family/Friends Agency Assistance No Source Not a Need
Food
Clothing
Housing/Shelter
Transportation
Child Care Services
Immediate Crisis Assistance
Utilities (fuel, electric, etc.)

Question Title

* 4. Which of the following activities have you participated in during the past twelve (12) months?  Please check all that apply.

Question Title

* 5. Please tell us how much of a problem the following barriers are to you and your family in seeking or gaining assistance with your basic needs.

  Not a Problem at All Somewhat of a Problem Big Problem
Inadequate Transportation/Distance
Concern About Confidentiality
Programs Not Available in the Area
Not Eligible/Don't Qualify for Assistance
Don't Know Where to Go for Help
Services Available During Limited Hours
Can't Afford Fees or Costs (co-payments, etc)
Poor Health/Disabilities Make it Difficult to Get There
Don't Know What the Guidelines/Rules of Eligibility Are
Pride (Don't want to ask for help)
Can't Read
Too Much Trouble/Red Tape
Had a Prior Bad Experience
Lack of Child Care
Drug or Alcohol Usage

Question Title

* 6. Do you need child care services?

Question Title

* 7. Which of the following have you found to be barriers to obtaining child care services? Please check all that apply.

Question Title

* 8. Please indicate which of the following you feel are barriers to FINDING employment. Please check all that apply.

Question Title

* 9. Please indicate which of the following you feel are barriers to MAINTAINING/KEEPING employment. Please check all that apply.

Question Title

* 10. What is your age?

Question Title

* 11. What is your gender?

Question Title

* 12. What is your marital status?

Question Title

* 13. Are you a single parent?

Question Title

* 14. Which of the following best describes the type of dwelling you live in?

Question Title

* 15. How many people, including yourself, live in your residence?

Question Title

* 16. Which of the following best describes the community where you live?

Question Title

* 17. What is the highest level of formal education you have received?

Question Title

* 18. Please indicate how many people in your household, 18 years and older, are currently in each of the following work categories. Put the number of people in your household in the box by each category that applies to them.

Question Title

* 19. Do you have to work more than one job?

Question Title

* 20. How many members of your household DO NOT currently have some type of health insurance including Medicaid, Medicare, or other Government programs?

Question Title

* 21. How many of those NOT currently covered by some type of health insurance are children under the age of 18?

Question Title

* 22. How many times in the past twelve (12) months have you NEEDED dental care but were unable to see a dentist?

Question Title

* 23. How many times in the past twelve (12) months did you RECEIVE dental care?

Question Title

* 24. If you were not able to see a dentist, please tell us why. Please check all that apply.

Question Title

* 25. Do you have enough money to meet you/your family's basic needs (food, shelter, clothing, etc.)?

Question Title

* 26. What do you need to help you become more self-sufficient or independent? Please check all that apply.

Question Title

* 27. What is your total yearly household income, from all sources, before taxes are taken out?

Question Title

* 28. Do you own a car?

Question Title

* 29. Do you have Internet access?

Question Title

* 30. If yes to Question #29, where do you have Internet access? Please check all that apply.

Question Title

* 31. Do you have a phone?

Question Title

* 32. Choose the description that best fits your opinion of each statement below.

  Strongly Agree Agree Somewhat Disagree Disagree Strongly Disagree
I felt welcomed and was treated in a dignified and respectful manner.
I felt staff listened to me and responded appropriately by providing information and/or assistance.
I am satisfied with the services I received or the program I accessed.
I would recommend BROC Community Action to a friend or family member.
The facilities/parking/environment were suitable for the services I received.

Question Title

* 33. Please rate your OVERALL satisfaction with the services you received or programs you accessed.

  Extremely Satisfied Satisfied Somewhat Dissatisfied Dissatisfied Extremely Dissatisfied
Overall

Question Title

* 34. Please share ways that BROC Community Action can improve its delivery of programs and services to better meet your needs.

Question Title

* 35. If you would like to be entered in a drawing to win a gift card, please fill out your information below. If not, please skip to the next question. 

Question Title

* 36. If you would like more information about programs and services, please indicate below which one(s) you are interested in.

T