Community Needs Assessment 2017 Question Title * 1. The zip code where you live: Medina County (If you live in Wayne County, see question #2) 44212 44215 44233 44235 44251 44253 44254 44256 44258 44273 44274 44275 44280 44281 Question Title * 2. The zip code where you live: Wayne County (If you live in Medina County, see question #1) 44214 44217 44230 44270 44276 44287 44606 44618 44627 44636 44645 44659 44667 44676 44677 44691 Question Title * 3. Your gender Male Female Non-binary/Third gender Prefer to self-describe Question Title * 4. Your marital status Single and never married Living with a partner in a committed relationship Married Separated Divorced Widow/Widower Question Title * 5. Highest level of education completed Some high school High school or GED Some college 2-year degree 4-year degree or higher Question Title * 6. Which best describes your racial or ethnic background (check all that apply) White Black or African American Hispanic or Latino American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Two or more Races Other (please specify) Question Title * 7. What is your current age 18-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 86-90 90 or older Question Title * 8. Total number of persons living in your home 1 2 3 4 5 6 7 8 9 or more Question Title * 9. How many adults live in your home 1 2 3 4 5 or more Question Title * 10. How many adults over 65 years old live in your home None 1 2 3 or more Question Title * 11. How many children live in your home under the age of 18 None 1 2 3 4 5 or more Question Title * 12. If one or more children under the age of 5 are in your home, have any participated in the following: Preschool Child care provided by family Child care provided by a center Head Start/Early Head Start Special Education Doesn't apply Question Title * 13. People in your home have child care that is affordable Yes No Doesn’t Apply Question Title * 14. Total 2016 household income before taxes (ranges reflect guidelines for federal assistance) $0-$12,060.00 $12,061.00-$16,240.00 $16,241.00-$20,420.00 $20,421.00-$24,600.00 $24,601.00-$28,780.00 $28,781.00-$32,960.00 $32,961.00-$37,140.00 $37,141.00-$41,320.00 $41,321.00-or higher Question Title * 15. Have you experienced a serious loss of income in the last 12 months Yes No Question Title * 16. What are your household sources of income (include all that apply) Employment Unemployment Temporary Assistance to Needy Families (TANF) Social Security Supplemental Security Income (SSI) Supplemental Security Disability (SSD) Pension Child Support Self Employed Other (please specify) Question Title * 17. People in your home have the ability to budget money Yes No Question Title * 18. Your mortgage or rent payments are affordable Yes No Doesn’t Apply Question Title * 19. You have enough money to pay other monthly bills Yes No Doesn’t Apply Question Title * 20. Do you have to make hard choices to decide what to pay Yes No Doesn’t Apply Question Title * 21. What language is mostly spoken at home English Spanish Other (please specify) Question Title * 22. People in your home are able to read and write English Yes No Doesn’t Apply Question Title * 23. Your neighborhood is safe Yes No Question Title * 24. Is your housing safe to live in (condition of home) Check all that apply Yes (if yes, go to question #25) No (if no, select area(s) below which are not safe) Reliable source of heat Hot running water Reliable electricity Sound roof Accessible Question Title * 25. Your home is adequately weatherized Yes No Doesn’t Apply Question Title * 26. Your type of home is best described as follows: Single-Family House Two-Family House Apartment Condominium or Townhouse Mobile Home Temporary Shelter or Temporary Living Arrangement Other (please specify) Question Title * 27. Housing is as follows: Homeowner Staying with Family or Friends Renting Other (please specify) Question Title * 28. Have you moved in the last 12 months Yes No Question Title * 29. If you have moved, how many times have you moved in the last 12 months 1 2 3 4 or more Question Title * 30. Have you been homeless in the last 12 months Yes No Question Title * 31. Do all people in the home that can work have a stable job Yes No Doesn’t apply Question Title * 32. What is your current employment status Employed full-time Employed part-time Unemployed Retired Other (please specify) Question Title * 33. If unemployed or seeking better employment, what could CAW/M provide that would help you most with employment (Check all that apply) Software Training Job Search Help Interview Skills Dressing for Success Resume Writing Math Refresher Reading Refresher Writing Refresher Life Skills Budgeting Other (please specify) Question Title * 34. Which best describes your typical work hours Traditional-(Monday-Friday during the day) Non-Traditional (Evenings, Weekends, etc.) Question Title * 35. People in your home have a regular way to get to work (reliable transportation) Yes No Doesn’t Apply Question Title * 36. Compared with people your age, how would you rate your health Much better than average A little better than average Average A little below average Well below average Question Title * 37. People in your home have a regular doctor to see Yes No Question Title * 38. People in your home have a regular dentist to see Yes No Question Title * 39. People in your home have health insurance Yes No Question Title * 40. People in your home have dental insurance Yes No Question Title * 41. People in your home have enough food to eat Yes No Question Title * 42. People in your home know how to get the public assistance or local services they need Yes No Question Title * 43. What is your knowledge of Community Action Wayne/Medina I knew about the agency before this survey I did not know about the agency until this survey Question Title * 44. What CAW/M services have you used in the past (check all that apply) Emergency Home Repair Head Start/Early Head Start Home Energy Assistance Program (HEAP) or Utility Assistance (PIPP) Home Weatherization Assistance Program (HWAP) Tax Preparation Food Pantry Getting Ahead Transportation Car Repair Car Safety Seats I Do Not Know None Other (please specify) Question Title * 45. Do you think that CAW/M provides important services Yes No Unsure Question Title * 46. Do you find CAW/M agency hours of operation are convenient Yes No Question Title * 47. What do you think are the major causes of poverty where you live? (Check all that apply) Divorce Lack of training Lack of education Not enough jobs Low motivation Poor housing Not enough government help Unsure Other (please specify) Question Title * 48. For this section, please mark any services you believe you or someone in your household would use in the next 12 months (Check all that apply) Children: Head Start/Early Head Start Childcare/Day care Childcare full-day Childcare part-day Childcare with alternative hours Car Seats Recreation Summer food programs Tutoring programs After school programs Other (please specify) Question Title * 49. For this section, please mark any services you believe you or someone in your household would use in the next 12 months: (Check all that apply)Finance/Assistance: Budgeting classes Foreclosure counseling Help repairing credit problems Homebuyers training Job-hunting training Matched savings program Tenant services Utility payment assistance Low interest loans Purchase of a car Credit education Emergency home repair Food pantry Help starting a small business Home weatherization Plant/seed program Tax return preparation Transportation Other (please specify) Question Title * 50. For this section, please mark any services you believe you or someone in your household would use in the next 12 months: (Check all that apply)Self Help: Adult daycare Computer skills training GED instruction Mental health services Substance abuse services Re-entry program Other (please specify) Question Title * 51. Your comments welcome! Question Title * 52. Please use the space below to tell us how our agency would be best able to serve you: Question Title * 53. Thank you for helping us help you! Done
