CAANE Community Needs Assessment Participant Survey

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* 1. In what county do you live?

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* 2. How many Adults (ages 18+) live in your household?

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* 3. How many children ages 17 and younger live in your household?

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* 4. What is YOUR current employment status? (check all that apply)

Full-Time

Unemployed

Student

Part-Time

Disabled

Seeking

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* 5. What is your gender?

Female

Male

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* 6. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75+

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* 7. What is your race? (check one)

White

Black or African-American

American Indian or Alaskan Native

Native Hawaiian or other Pacific Islander

Asian

From multiple races

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* 8. What is your ethnicity? (check one)

I am not Spanish, Hispanic, or Latino

Mexican

Mexican-American

Cuban

Cuban-American

Chicano

Puerto Rican

Some Other Spanish, Hispanic or Latino Group

From multiple Spanish, Hispanic or Latino groups

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* 9. What is the highest level of education you have completed? (check one)

Less than 10th Grade

11th-12th grade

High School/GED

Associate degree

Bachelor degree

Masters degree or higher

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* 10. Do you currently have health insurance?

Yes

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* 11. Do you rent or own the place you live?

Rent

Own

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* 12. Is anyone in your household a veteran or in the military?

Yes

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* 13. Do you have a checking or savings account with a bank or credit union?

Yes

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* 14. In your community, have you ever served as a volunteer of a civic organization?

Yes

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* 15. In your community, have you ever served as a Board member of a civic organization?

Yes

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* 16. Tell us how YOU are doing. Circle the number below the issue that best describes how you are. 1 = In Crisis; 2 = Vulnerable; 3 = Stable; 4 = Self-Sufficient; 5 = Thriving

	1	2	3	4	5
Employment	Employment 1	Employment 2	Employment 3	Employment 4	Employment 5
Income	Income 1	Income 2	Income 3	Income 4	Income 5
Household Budgeting	Household Budgeting 1	Household Budgeting 2	Household Budgeting 3	Household Budgeting 4	Household Budgeting 5
Adult Education/HS Diploma/GED/College	Adult Education/HS Diploma/GED/College 1	Adult Education/HS Diploma/GED/College 2	Adult Education/HS Diploma/GED/College 3	Adult Education/HS Diploma/GED/College 4	Adult Education/HS Diploma/GED/College 5
Job Training (your job skills assessment)	Job Training (your job skills assessment) 1	Job Training (your job skills assessment) 2	Job Training (your job skills assessment) 3	Job Training (your job skills assessment) 4	Job Training (your job skills assessment) 5
Housing (your current housing)	Housing (your current housing) 1	Housing (your current housing) 2	Housing (your current housing) 3	Housing (your current housing) 4	Housing (your current housing) 5
Medical Care/Adult Health & Dental Coverage	Medical Care/Adult Health & Dental Coverage 1	Medical Care/Adult Health & Dental Coverage 2	Medical Care/Adult Health & Dental Coverage 3	Medical Care/Adult Health & Dental Coverage 4	Medical Care/Adult Health & Dental Coverage 5
Transportation	Transportation 1	Transportation 2	Transportation 3	Transportation 4	Transportation 5
Childcare	Childcare 1	Childcare 2	Childcare 3	Childcare 4	Childcare 5
Mental/Emotional Health	Mental/Emotional Health 1	Mental/Emotional Health 2	Mental/Emotional Health 3	Mental/Emotional Health 4	Mental/Emotional Health 5
Alcohol or Substance Dependency	Alcohol or Substance Dependency 1	Alcohol or Substance Dependency 2	Alcohol or Substance Dependency 3	Alcohol or Substance Dependency 4	Alcohol or Substance Dependency 5
Nutrition	Nutrition 1	Nutrition 2	Nutrition 3	Nutrition 4	Nutrition 5
Domestic Violence	Domestic Violence 1	Domestic Violence 2	Domestic Violence 3	Domestic Violence 4	Domestic Violence 5
Pregnancy/Infant Care	Pregnancy/Infant Care 1	Pregnancy/Infant Care 2	Pregnancy/Infant Care 3	Pregnancy/Infant Care 4	Pregnancy/Infant Care 5
Family Relations/Support	Family Relations/Support 1	Family Relations/Support 2	Family Relations/Support 3	Family Relations/Support 4	Family Relations/Support 5
Parenting Skills	Parenting Skills 1	Parenting Skills 2	Parenting Skills 3	Parenting Skills 4	Parenting Skills 5
Legal Issues/Probation/Parole/Warrants	Legal Issues/Probation/Parole/Warrants 1	Legal Issues/Probation/Parole/Warrants 2	Legal Issues/Probation/Parole/Warrants 3	Legal Issues/Probation/Parole/Warrants 4	Legal Issues/Probation/Parole/Warrants 5

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* 17. What issues concern you most in YOUR COMMUNITY? (choose only 5 issues, then rank them in order of concern with 1 being least concern and 5 being most concern)

	1	2	3	4	5
Literacy Needs, access to library, bookmobile, etc.	Literacy Needs, access to library, bookmobile, etc. 1	Literacy Needs, access to library, bookmobile, etc. 2	Literacy Needs, access to library, bookmobile, etc. 3	Literacy Needs, access to library, bookmobile, etc. 4	Literacy Needs, access to library, bookmobile, etc. 5
Need for more job training	Need for more job training 1	Need for more job training 2	Need for more job training 3	Need for more job training 4	Need for more job training 5
Not enough jobs	Not enough jobs 1	Not enough jobs 2	Not enough jobs 3	Not enough jobs 4	Not enough jobs 5
Adult education opportunities	Adult education opportunities 1	Adult education opportunities 2	Adult education opportunities 3	Adult education opportunities 4	Adult education opportunities 5
Homelessness	Homelessness 1	Homelessness 2	Homelessness 3	Homelessness 4	Homelessness 5
Affordable, safe housing	Affordable, safe housing 1	Affordable, safe housing 2	Affordable, safe housing 3	Affordable, safe housing 4	Affordable, safe housing 5
Lack of transportation	Lack of transportation 1	Lack of transportation 2	Lack of transportation 3	Lack of transportation 4	Lack of transportation 5
Services for disabled children and families	Services for disabled children and families 1	Services for disabled children and families 2	Services for disabled children and families 3	Services for disabled children and families 4	Services for disabled children and families 5
Teen Pregnancy	Teen Pregnancy 1	Teen Pregnancy 2	Teen Pregnancy 3	Teen Pregnancy 4	Teen Pregnancy 5
Food for the low-income	Food for the low-income 1	Food for the low-income 2	Food for the low-income 3	Food for the low-income 4	Food for the low-income 5
Food for the Elderly	Food for the Elderly 1	Food for the Elderly 2	Food for the Elderly 3	Food for the Elderly 4	Food for the Elderly 5
Schools and education for children	Schools and education for children 1	Schools and education for children 2	Schools and education for children 3	Schools and education for children 4	Schools and education for children 5
Cost of utilities (gas, water, electricity)	Cost of utilities (gas, water, electricity) 1	Cost of utilities (gas, water, electricity) 2	Cost of utilities (gas, water, electricity) 3	Cost of utilities (gas, water, electricity) 4	Cost of utilities (gas, water, electricity) 5
Child Abuse & Neglect	Child Abuse & Neglect 1	Child Abuse & Neglect 2	Child Abuse & Neglect 3	Child Abuse & Neglect 4	Child Abuse & Neglect 5
Alcohol & Substance Abuse	Alcohol & Substance Abuse 1	Alcohol & Substance Abuse 2	Alcohol & Substance Abuse 3	Alcohol & Substance Abuse 4	Alcohol & Substance Abuse 5
Domestic violence awareness	Domestic violence awareness 1	Domestic violence awareness 2	Domestic violence awareness 3	Domestic violence awareness 4	Domestic violence awareness 5

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* 18. What issues concern you most in YOUR FAMILY? (choose only 5 issues, then rank them in order of concern with 1 being least concern and 5 being most concern)

	1	2	3	4	5
Job training	Job training 1	Job training 2	Job training 3	Job training 4	Job training 5
Employment	Employment 1	Employment 2	Employment 3	Employment 4	Employment 5
Food	Food 1	Food 2	Food 3	Food 4	Food 5
Education for adults (GED, etc.)	Education for adults (GED, etc.) 1	Education for adults (GED, etc.) 2	Education for adults (GED, etc.) 3	Education for adults (GED, etc.) 4	Education for adults (GED, etc.) 5
Lack of books, reading materials in my home	Lack of books, reading materials in my home 1	Lack of books, reading materials in my home 2	Lack of books, reading materials in my home 3	Lack of books, reading materials in my home 4	Lack of books, reading materials in my home 5
Paying necessary bills (rent, electric, phone)	Paying necessary bills (rent, electric, phone) 1	Paying necessary bills (rent, electric, phone) 2	Paying necessary bills (rent, electric, phone) 3	Paying necessary bills (rent, electric, phone) 4	Paying necessary bills (rent, electric, phone) 5
Affordable, safe housing	Affordable, safe housing 1	Affordable, safe housing 2	Affordable, safe housing 3	Affordable, safe housing 4	Affordable, safe housing 5
Transportation and fuel costs	Transportation and fuel costs 1	Transportation and fuel costs 2	Transportation and fuel costs 3	Transportation and fuel costs 4	Transportation and fuel costs 5
Child care for infants, toddlers & after school	Child care for infants, toddlers & after school 1	Child care for infants, toddlers & after school 2	Child care for infants, toddlers & after school 3	Child care for infants, toddlers & after school 4	Child care for infants, toddlers & after school 5
Services for disabled child	Services for disabled child 1	Services for disabled child 2	Services for disabled child 3	Services for disabled child 4	Services for disabled child 5
Getting dental care (adults)	Getting dental care (adults) 1	Getting dental care (adults) 2	Getting dental care (adults) 3	Getting dental care (adults) 4	Getting dental care (adults) 5
Getting mental health services	Getting mental health services 1	Getting mental health services 2	Getting mental health services 3	Getting mental health services 4	Getting mental health services 5
Getting Child Support Assistance	Getting Child Support Assistance 1	Getting Child Support Assistance 2	Getting Child Support Assistance 3	Getting Child Support Assistance 4	Getting Child Support Assistance 5
Incarcerated Parents	Incarcerated Parents 1	Incarcerated Parents 2	Incarcerated Parents 3	Incarcerated Parents 4	Incarcerated Parents 5
Getting Domestic Violence Assistance	Getting Domestic Violence Assistance 1	Getting Domestic Violence Assistance 2	Getting Domestic Violence Assistance 3	Getting Domestic Violence Assistance 4	Getting Domestic Violence Assistance 5
Money Management/Budgeting	Money Management/Budgeting 1	Money Management/Budgeting 2	Money Management/Budgeting 3	Money Management/Budgeting 4	Money Management/Budgeting 5
Home Repair	Home Repair 1	Home Repair 2	Home Repair 3	Home Repair 4	Home Repair 5

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* 1. In what county do you live?

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* 2. How many Adults (ages 18+) live in your household?

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* 3. How many children ages 17 and younger live in your household?

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* 4. What is YOUR current employment status? (check all that apply)

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* 5. What is your gender?

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* 6. What is your age?

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* 7. What is your race? (check one)

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* 8. What is your ethnicity? (check one)

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* 9. What is the highest level of education you have completed? (check one)

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* 10. Do you currently have health insurance?

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* 11. Do you rent or own the place you live?

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* 12. Is anyone in your household a veteran or in the military?

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* 13. Do you have a checking or savings account with a bank or credit union?

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* 14. In your community, have you ever served as a volunteer of a civic organization?

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* 15. In your community, have you ever served as a Board member of a civic organization?

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* 16. Tell us how YOU are doing. Circle the number below the issue that best describes how you are. 1 = In Crisis; 2 = Vulnerable; 3 = Stable; 4 = Self-Sufficient; 5 = Thriving

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* 17. What issues concern you most in YOUR COMMUNITY? (choose only 5 issues, then rank them in order of concern with 1 being least concern and 5 being most concern)

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* 18. What issues concern you most in YOUR FAMILY? (choose only 5 issues, then rank them in order of concern with 1 being least concern and 5 being most concern)

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* 19. Was CAANE able to serve your needs?

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* 20. Did the staff treat you with courtesy and respect?

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* 21. Please tell us about the services you or your family received?