Help us build a healthier Community by taking our Community Needs Assessment Survey. This information will help to provide much needed outreach and wellness programs in the area, keeping you and your family as healthy as possible. The results from this survey are confidential.

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* 1. What is your zip code?

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* 2. Gender

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* 3. Age range

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* 4. Highest level of education

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* 5. Household Income (per year)

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* 6. What is your race/ethnicity?

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* 7. What do you believe is the biggest health problem in your community? (Check all that you think apply)

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* 8. What do you think are the problems that keep you or other community members from getting healthcare they need? (Check all that you think apply)

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* 9. Do you have any ideas or recommendations to help decrease the health problems in the community or to solve the problems with access to health services?

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* 10. What are the greatest strengths of your community? (Check all that apply)

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* 11. What are the greatest weaknesses of your community? (Check all that apply)

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* 12. What is the level of healthcare need in the following areas as they exist within your community? (Please select a response of High, Low, No need, or Don't know for each type of health concern.)

  High Low No need Don't know
Primary care
Specialty care
Dental care
Eye care
Substance abuse
Mental health
Transportation to healthcare appointments

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* 13. What is the level of nutritional need in the following areas as they exist within your community? (Please select a response of High, Low, No need, or Don't know for each.)

  High Low No need Don't know
Access to affordable healthy foods
Access to healthy food in schools
Access to healthy food in stores

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* 14. What is a source of stress in your daily life? (Please select a response of High, Low, None, or Don't know for each.)

  High Low None Don't know
Relationships
Fear of domestic violence
Access to health care services
Access to food
Access to transportation
Access to safe housing
Access to education
Community violence

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* 15. What is the greatest transportation need as it exists in your community? (Please select a response of High, Low, No need, or Don't know for each.)

  High Low No need Don't know
Transportation to health care
Transportation to work
Transportation to grocery stores
Reliable, scheduled transportation
Affordable transportation
Transportation to community activities

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* 16. What is the level of language barrier you experience in your community? (Please select a response of High, Low, None or Don't know for each.)

  High Low None Don't know
Access to multi-lingual services
Access to language skill education
Access to employment in your first language

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* 17. What is the greatest substance abuse need in the following areas? (Please select a response of High, Low, No need, or Don't know for each).

  High Low No need Don't know
Prevention programs
Reduction of drug use
Reduction of prescription drug use
Access to treatment - outpatient
Access to treatment - residential
Reduction of alcohol abuse
Drug specific treatment: ___________________________

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* 18. What is the greatest mental health need for the following areas as they exist in your community? (Please select a response of High, Low, No need, or Don't know for each)

  High Low Ne need Don't know
Residential mental health treatment
Mental health professionals
Prevention
Access to treatment

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* 19. What is the greatest housing need as it exists within your community? (Please select a response of High, Low, No need, or Don't know for each.)

  High Low No need Don't know
Resident advocacy
Senior housing
Affordable housing
Access to loans
Financial literacy

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* 20. What is the greatest employment need as it exists within your community? (Please select a response of High, Low, No need, or Don't know for each.)

  High Low No need Don't know
Job search and placement assistance
Incoming generating skills
Internships, paid, leadership, or volunteer work opportunities

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* 21. What would improve the quality of life for you within your community? Please rank the level of need in the following areas. (Please select a response of High, Low, No need, or Don't know for each.)

  High Low No need Don't know
Educational opportunities
Housing
Recreational opportunities
Community safety
Healthcare access
Dental care access
Public transportation
Substance abuse support
Mental health services
Employment opportunities
Community activities
After school programs
Partnership with local police department
Connections to resources/community agencies
Access to local parks and community classes
Trails and paths

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* 22. What is the greatest education need? (Please select a response of High, Low, No need, or Don't know for each.)

  High Low No need Don't know
Childhood development
Youth development
Access to the ourdoors
Nutrition and physical exercise
Life skills trainings
Parenting classes
Health education
Adult education
Day care
Quality of available education
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