* 1. Please select the position listed that best describes you.

* 2. County:

* 3. Name:

* 4. Title:

* 5. Please rank the following EMPLOYMENT SUPPORT needs for your area.

  Unsure if a Need Low Need Somewhat a Need Definitely a Need High Need
Employment Initiative (job training, etc.)
Higher Wages & Benefits
GED Program
Post-Secondary Education Opportunities
Before & After School Child Care
Tuition Assistance

* 6. Please rank the following EMERGENCY SERVICES needs in your area.

  Unsure if a Need Low Need Somewhat a Need Definitely a Need High Need
Emergency Food Assistance
Emergency Fuel/Energy Assistance
Temporary Shelter
Emergency Medical Care
Protection from Domestic Violence
Rent/Mortgage Assistance

* 7. Please rank the following CHILD & FAMILY DEVELOPMENT needs in your area.

  Unsure if a Need Low Need Somewhat a Need Definitely a Need High Need
Vulnerability of Low-Income, Seniors and Disabled Persons
Enrichment Programs for Youth
Family Counseling
Chemical Dependence Counseling Treatment
Parenting Skills
School Readiness
Financial Management/Budgeting

* 8. Please rank the following MISCELLANEOUS needs in your area.

  Unsure if a Need Low Need Somewhat a Need Definitely Need High Need
Health Care Services
Public Transportation/Car Repairs
Affordable Housing (rental/ownership)
Home Repairs Programs
Asset Building Services
Prescription Assistance
Dental Services
Legal Services

* 9. Please check the causes you see as to why your area needs the above mentioned services.

* 10. What resources are you aware of that may help to address the needs in the above questions?

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