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County of Riverside
Community Action Partnership
Community Member Needs Survey
2.
DEMOGRAPHIC INFORMATION
1.
How many people live in your household?
1
2
3
4
5
6
7
8
9
10
11
12
2.
What is your gender?
Female
Male
Other
Decline to state
3.
What is the primary language spoken in your household?
English
Spanish
Other (please specify)
4.
Are you of Hispanic, Latino or Spanish origin?
No; not of Hispanic, Latino or Spanish origin
Yes; Hispanic, Latino or Spanish origin
5.
What is your race?
Check all that apply
Black/African American
Asian
Native Hawaiian
White
American Indian or Alaska Native
Decline to state
Other (please specify)
6.
What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 61
62 and older
7.
What are the ages of the
other
people living in your home? (Indicate how many)
1
2
3
4
5
6
7
8
9
Age 0-3
1
2
3
4
5
6
7
8
9
Age 4
1
2
3
4
5
6
7
8
9
Age 5
1
2
3
4
5
6
7
8
9
Age 6-11
1
2
3
4
5
6
7
8
9
Age 12-17
1
2
3
4
5
6
7
8
9
Age 18-24
1
2
3
4
5
6
7
8
9
Age 25-55
1
2
3
4
5
6
7
8
9
Age 56-64
1
2
3
4
5
6
7
8
9
Age 65-74
1
2
3
4
5
6
7
8
9
Age 75+
1
2
3
4
5
6
7
8
9
8.
What city do you live in?
City:
ZIP code:
9.
What is the highest level of education you have completed?
Less than a high school degree
High school diploma/HSE/GED
Trade/Vocational school
Some college
Associate’s degree
Bachelor’s degree
Graduate degree or professional degree
10.
Which best describes your marital status?
Single
Married
Divorced
Separated
Widowed
Living with partner
11.
What have been your household’s top
THREE
needs within the past 12 months?
Check three that apply:
Adult education/Literacy
Animal Care / Spay/Neuter Services
Child care
College Education
Dental care
Domestic violence assistance
Employment
English (ESL) Classes
Financial assistance
Food assistance
Health care
Heating/Utility assistance
Job/Employment training
Legal assistance
Mental health services
Parenting education
Rental/Housing assistance
Safe, affordable housing
Senior citizen services
Substance abuse
Transportation
Youth programs/Tutoring
None of the above
Other (please specify)
12.
Check
ALL
of the services that you or someone in your household needed but did
NOT
receive within the past 12 months.
Check all that apply
Adult education/literacy
Animal Care / Spay/Neuter Services
Child care
College Education
Dental care
Domestic violence assistance
Employment
English (ESL) Classes
Financial assistance
Food assistance
Health care
Heating/utility assistance
Job/employment training
Legal assistance
Mental health services
None of the above
Parenting education
Rental/Housing assistance
Safe, affordable housing
Safety/crime prevention
Senior citizen services
Substance abuse assistance
Transportation
Veteran’s services
Youth programs/Tutoring
Other (please specify)
13.
If you needed services and did not get them, what was the reason?
I was unable to get to the service location
The service I needed was not available
I did not know about the service
Does not apply
Other (please specify)
17%
