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Wish List
2018 Grundy County Nonprofit Wish List & Capacity Survey
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1.
Organization Name
(Required.)
2.
Name of specific program within the organization (please fill out a separate survey for each program if appropriate)
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3.
Program Address
(Required.)
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4.
Website (program or organization)
(Required.)
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5.
Program E-mail:
(Required.)
6.
Please list your organization/program social networking sites:
Facebook ID:
Twitter ID:
LinkedIn ID:
Other:
Other:
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7.
Is your organization or program a 501c3 charitable organization?
(Required.)
Yes
No
If not, what is your IRS designation?
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8.
Is your organization/program a unit of local government?
(Required.)
Yes
No
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9.
Can your organization/program receive charitable donations?
(Required.)
Yes
No
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10.
Does your organization receive state or federal funding?
(Required.)
Yes
No
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11.
What are three things your program/organization does really well?
(Required.)
1st
2nd
3rd
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12.
What three things do you wish your program/organization could do better?
(Required.)
1st
2nd
3rd
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13.
What tangible needs does your organization or program have that donors can help provide?
(Required.)
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14.
If money were no object, what would you wish for your organization and/or clients?
(Required.)
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15.
Of that wish list, what items are realistic and achievable with the right resources (other than fixing the State problems or winning the lottery)?
(Required.)
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16.
If donors come for a site visit, what will you show them?
(Required.)
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17.
What volunteer opportunities do you offer - both on-going and special projects?
(Required.)
On-going
Special
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18.
What services does your organization/program provide?
(Required.)
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19.
Which population(s) does your organization/program serve? Please select all that apply.
(Required.)
Early Childhood (birth to 5)
Children (ages 6 to 11)
Adolescent (ages 12 to 17)
Young Adult (ages 18 to 26)
Adults (ages 27 to 64)
Seniors (ages 65 & up)
Families
College Students
Disabled
Veterans/Active Military
Homeless
Undocumented Individuals
Other (please specify)
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20.
How many clients does your program serve in total?
(Required.)
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21.
How many clients does your program serve in Grundy County?
(Required.)
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22.
How do clients pay for your services? Please choose all that apply.
(Required.)
Private Insurance
Medicaid
Medicare
Sliding Scale/Self-pay
Fixed Price/Self-pay
No charge
Other
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23.
What is the typical wait time to receive your services?
(Required.)
No wait
1-7 days
8-14 days
15-31 days
1-2 months
3-4 months
5-6 months
more than 6 months
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24.
Based on your observations and interactions, which age groups struggle to find services in general? Please choose all that apply.
(Required.)
Early Childhood (ages 0 to 5)
Childhood (ages 6 to 11)
Adolescents (ages 12 to 17)
Young Adults (ages 18 to 26)
Adults (ages 27 to 64)
Senior (ages 65 & up)
Other (please specify)
25.
What barriers do clients/residents face that make it difficult to access services and programs in general, not just yours? (check all that apply)
lack of insurance
distance to services
lack of transportation
hours of service (lack of evening and weekend hours)
client/patient resistance
family dysfunction
Other (please specify)
26.
Please list any support groups provided by your organization and/or support groups in the community that you are aware of:
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27.
Does your organization have plans to increase service capacity (additional staff, site, program, etc.) within the next 12 to 18 months?
(Required.)
Yes
No
Unsure
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28.
Any last comments we have forgotten to ask that you'd like to share with clients, donors, volunteers, and supporters?
(Required.)
29.
What are the barriers for service capacity expansion? Please choose all that apply.
Lack of capital funding for facility expansion
Low Medicaid or State reimbursement rates
Governmental rules or regulations preventing expansion
Restrictive management of insurance benefits
Restrictive management of Medicaid benefits
Restrictive management of Medicare benefits
No perceived need
Instability of State Funding
Other (please specify)
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30.
Is your organization involved in prevention education or other prevention strategies?
(Required.)
Yes
No
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31.
If you could change one thing about the system for health & social services in Grundy County, what would it be?
(Required.)