Community Assessment Children Survey

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* 1. Do you live in East Baton Rouge Parish

Yes

Other (please specify)

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* 2. Race

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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* 3. Any pregnant women/mothers within your household?

Yes

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* 4. Any children age 5 or younger receiving services through Early Steps (IFSP) or School Board (IEP)?

Yes

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* 5. Do you currently have children or grandchildren in Head Start?

Yes

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* 6. Gender

Male

Female

Transgender

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* 7. Age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 8. Is your income enough to meet your family's basic needs?

Yes

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* 9. Whats your annual income range?

$0.00 - $25,000 Annually

$25,001 - $35,000 Annually

$35,001 - $45,000 Annually

$45,001 - or more Annually

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* 10. Which best describes you and your family food and clothing needs.

We meet our basic food & clothing needs

We meet our basic food & clothing needs with some help from public programs or subsidies

We often do not have enough food & clothing

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* 11. Which best describes you and your family housing needs.

We have our own housing that is stable.

We share living space with others or reside in a public subsidized housing.

We have unstable housing, or experiencing homelessness, or at risk of eviction.

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* 12. Which best describes you and your family health care needs.

My family and I are healthy and we have access to medical and dental care. We visit our health providers regularly.

We have access to medical and dental care but we do not visit our health providers regularly.

We do not have access to medical or dental care.

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* 13. Would you, or a member of your family, like to receive counseling or assistance in dealing with stress, anxiety, depression, or addiction?

Yes

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* 14. Have you or a member of your family received mental health services/treatment within the past year?

Yes

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* 15. Employment

I have a permanent job

I am self-employed

I have a temporary job or do not work enough hours

I do not have a job or I am looking for employment

I choose not to work

Other (please specify)

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* 16. Parenting Skills

I can deal with my child's behavior

I have some difficulty dealing with my child's behaviors

Being a parent is a struggle for me. I want to learn more about parenting skills

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* 17. Male/Father Engagement

There is a positive male role model in my child's life every day

There is a positive male role model for my child but not consistent

My child does not have a positive role model in his/her life

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* 18. Learning and Development

I am very involved in my child's learning and development. I know of many learning activities to help my child learn and grow.

I am somewhat involved in my child's learning and development. I know of some learning activities to help my child learn and grow.

I want to be more involved in my child's learning and development. I also need learning activities to help my child learn and grow

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* 19. Family Literacy

My family has a daily routine when it comes to reading.

My family needs to spend more time reading.

My family does not engage in any literacy activity.

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* 20. Adult Education

I have attended the highest level of education I desire.

I am interested in going back to school to complete my degree (GED, high school, certification, college, etc.)

want to continue my education but need help with the English language or have other barriers that prevent me from obtaining or continuing my education.

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* 21. Professional Development

I am satisfied with my job/career

I want to change my job/career or want advancement in my job/career

I am in need of job training services, resume building, or professional development opportunities

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* 22. I am a:

Renter

Homeowner

Other (please specify)

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* 23. I can't afford to pay my rent/mortgage.

True

False

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* 24. I have missed a monthly payment at least (not paid /not paid on due date).

Once or twice in the past year

More than twice in the past year

I have not missed a monthly payment in the past year

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* 25. Are you or your family currently receiving rental assistance from any organization(s) (i.e. Church, Faith Based Organization, City of Baton Rouge, United Way, Salvation Army, etc.)?

Yes

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* 26. I am currently behind on my rent/mortgage.

Yes

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* 27. My current job does not pay me enough to afford my mortgage/rent.

Yes

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* 28. I currently have a checking or savings account with a banking institution.

Yes

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* 29. I use pay day loans to meet my bill/financial obligations.

Yes

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* 30. I borrow from family/friends to pay my bills.

A lot

A little

None at all

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* 31. Amount of your mortgage/rent per month?

Over $1,501 per month

$1,250 - $1,500 per month

$1,001 - $1,250 per month

$751 - $1,000 per month

$501 - $750 per month

$500 - or less per month

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* 32. Does your family have emergency or need immediate assistance in the following areas?

Food

Health Concerns

Housing /Shelter

Child Abuse

Clothing

Drug/Alcohol Abuse

Clothing

Drug/Alcohol Abuse

Utilities Assistance

Medication Assistance

Counseling

Domestic Violence

Other (please specify)

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* 33. Does your family currently receive any public benefits (SSI, WIC, Food Stamps/SNAP, Unemployment Benefits)?

Yes

Community Assessment Children