Community Assestment Survey

Question Title

* 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)

Question Title

* 2. Your Age Range: (choose one answer only)

18-25

26-35

36-50

51-65

65+

Other (please specify)

Question Title

* 3. Zipcode: (Write one answer only)

Question Title

* 4. Marital status: (choose one answer only)

Single

Married

Divorced/Separated/Widowed

Other (please specify)

Question Title

* 5. Do you have children under 18 years of age? (choose one answer only)

Question Title

* 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)

Question Title

* 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)

Question Title

* 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

Question Title

* 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)

Question Title

* 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)

Community Assestment Survey

Question Title

* 1. Please tell us about your connection to Marks JCH (choose one answer only)

Question Title

* 2. Your Age Range: (choose one answer only)

Question Title

* 3. Zipcode: (Write one answer only)

Question Title

* 4. Marital status: (choose one answer only)

Question Title

* 5. Do you have children under 18 years of age? (choose one answer only)

Question Title

* 6. What are your current child-related needs? (please select all that applies)

Question Title

* 7. If you are currently employed, what is your working condition? (please select all that applies)

Question Title

* 8. If you are currently unemployed:

Question Title

* 9. In the last 3 months, were you worried about (please select all that applies):

Question Title

* 10. What services are you interested in? (please select all that applies):

Question Title

* 11. The below fields are optional; all answers are kept confidential

Please list the top 1-3 concerns you have at this time:

Question Title

* 12. Full Name:

Question Title

* 13. Email:

Question Title

* 14. Are you interested in information about COVID-19 vaccine?

Community Assestment Survey

Question Title

* 1. Please tell us about your connection to Marks JCH (choose one answer only)

Question Title

* 2. Your Age Range: (choose one answer only)

Question Title

* 3. Zipcode: (Write one answer only)

Question Title

* 4. Marital status: (choose one answer only)

Question Title

* 5. Do you have children under 18 years of age? (choose one answer only)

Question Title

* 6. What are your current child-related needs? (please select all that applies)

Question Title

* 7. If you are currently employed, what is your working condition? (please select all that applies)

Question Title

* 8. If you are currently unemployed:

Question Title

* 9. In the last 3 months, were you worried about (please select all that applies):

Question Title

* 10. What services are you interested in? (please select all that applies):

Question Title

* 11. *The below fields are optional; all answers are kept confidential*Please list the top 1-3 concerns you have at this time:

Question Title

* 12. Full Name:

Question Title

* 13. Email:

Question Title

* 14. Are you interested in information about COVID-19 vaccine?

* 11. The below fields are optional; all answers are kept confidential

Please list the top 1-3 concerns you have at this time: