Haitian Community Needs Assessment Survey

This survey is designed to better understand the needs of the Haitian community in the United States. There are no right or wrong answers. We are interested in your perspective.  It should take no more than seven minutes to complete. And know that your responses will be kept completely anonymous, and will only be reported after being aggregated to insure your anonymity. 

Thank you for providing the Haitian American Caucus with your valuable insight.  Your input is very much appreciated.

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* 1. Please rate your overall level of satisfaction with your current quality of life.

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* 2. Please rate your overall level of satisfaction with services provided by the following government entities to address the needs of the Haitian community.

  Completely Satisfied Satisfied Neither satisfied or dissatisfied Dissatisfied Completely dissatisfied
Federal (i.e. USA) government services
State (e.g., NY, NJ, FL) government services
City and county government services

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* 3. Please rate your level of satisfaction with the following as they relate to you and your family.

  Completely satisfied Satisfied Neither satisfied or dissatisfied Dissatisfied Completely dissatisfied N/A
Your local area as a place to live
The house you live in
The hygiene around your home
The quality of your neighbors
Employment opportunities in your area
Access to life-long learning (adult education)
Access to high quality schools for children living in my local community
Access to good quality community activities
Being treated with dignity and respect within my local community
Access to affordable, high quality child care
Quality of emergency services (police, fire, medical, etc.) within my local community
Personal safety of me and my family

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* 4. How serious of a problem is each of the issues below for you and your family?

  Not a problem Relatively minor problem Somewhat serious problem Very serious problem
Immigration/Visa
Afford college
Cost of medical care
Elderly care
Children’s schools
College debt/student loans
Bullying
Paying mortgage
Childcare costs
Medical debt
Credit card debt

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* 5. Have you voted within the past two years? (check only one)

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* 6. Do you have a primary care physician? (check only one)

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* 7. Do you have health insurance

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* 8. For classification purposes, could you please let us know which of the following best describes your current age? (check only one)

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* 9. Which of the following best describes your gender? (check only one)

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* 10. Please select the follow category that best describes your ethnicity. (check only one)

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* 11. Please select the follow category that best describes your connection to the Haitian community (check only one)

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* 12. What is your marital status? (check only one)

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* 13. What is the highest degree or level of school you have completed? If currently enrolled, highest degree received?

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* 14. What is your current employment status?

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* 15. What is the current city in which you reside?

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* 16. How many years have you lived at your current address?

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* 17. Do any children age 12 or under live in your household?

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* 18. Do any teenagers between the ages of 13 and 17 live in your household?

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* 19. Are you or any members of your household between the ages of 18 and 22 live in your household?

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* 20. Are you or any members of your household age 65 or older?

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* 21. What was your total household income before taxes during the past 12 months?

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* 22. When was your most recent visit to Haiti?

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* 23. Have you donated to any organizations that support the needs of Haiti and the Haitian community in the United States within the past 2 years (i.e. 24 months)?

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* 24. What do you believe is the single most important issue that needs to be addressed in your community?

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