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Community Assestment Survey
1.
Please tell us about your connection to Marks JCH (choose one answer only)
Member
Parent of child attending programs
Attended programs (e.g. English classes, senior center, etc)
Received services (case management, job placement)
Other (please specify)
2.
Your Age Range: (choose one answer only)
18-25
26-35
36-50
51-65
65+
Other (please specify)
3.
Zipcode: (Write one answer only)
4.
Marital status: (choose one answer only)
Single
Married
Divorced/Separated/Widowed
Other (please specify)
5.
Do you have children under 18 years of age? (choose one answer only)
Yes
No
6.
What are your current child-related needs? (please select all that applies)
None
after school care
preschool or early childhood care
Enrichment classes such as swimming, sports, dance, art
Access to mental health services / services for kids with special needs
Other (please specify)
7.
If you are currently employed, what is your working condition? (please select all that applies)
Work from home
Work on site
Hybrid of at home and on site
Other (please specify)
8.
If you are currently unemployed:
One or more adults in your household have lost employment due to COVID-19.
You are receiving unemployment or other financial assistance
You are not receiving employment assistance
You are interested in re-employment
9.
In the last 3 months, were you worried about (please select all that applies):
Food security and your next meal
Anxiety/depression for any family member
Paying rent or mortgage
Job security
Social isolation
Access to services I typically receive (e.g. early intervention or a hot lunch program)
Access to medical care / my medication
Access to a computer/internet for any family member
Home care services/ home care assistance
Other (please specify)
10.
What services are you interested in? (please select all that applies):
food pantry or another meal program
domestic violence-related counseling
vocational training
job placement services
English classes
Support and information on rent/mortgage deferments and assistance available
mental health services referrals
referrals to free legal services
vocational training
COVID-19 vaccination/scheduling a vaccine
Other (please specify)
11.
*The below fields are optional; all answers are kept confidential*
Please list the top 1-3 concerns you have at this time:
12.
Full Name:
13.
Email:
14.
Are you interested in information about COVID-19 vaccine?
No, I am already vaccinated
Yes, I d like more information about it
No, not interested at this time
Other (please specify)
Current Progress,
0 of 14 answered