Community Assessment Survey (Clients) Question Title * 1. Which describes you and your relationship with Central Texas Opportunities, Inc. (check all that apply) CTO Board member Elected/Public Official Law Enforcement Personnel Teacher/Educator Business Community Faith Based Organization Community Partner Community Member Other (please specify) OK Question Title * 2. County of residence Brown Callahan Coleman Comanche Eastland McCulloch Runnels OK Question Title * 3. Your age? 18-29 30-39 40-49 50-59 60 && above OK Question Title * 4. Your gender? Male Female Other (please specify) OK Question Title * 5. What is your education level? 8th Grade of less Some High School High School Diploma/GED Some College Associated Degree Bachelor’s Degree or higher OK Question Title * 6. What is your race? American Indian Asian Black Native Hawaiian or Pacific Islander White Latino or Hispanic Mutiple Race OK Question Title * 7. What Language do you speak at home? English Spanish Other (please specify) OK Question Title * 8. What is your family situation? (check all that apply) Single Single parent Two parents Raising own and other children Raising child of other family members Raising someone else’s children, not family Shared custody OK Question Title * 9. Family Size/IncomeFamily of 1- 12,060Family of 2- 16,240Family of 3- 20,420Family of 4- 24,600Family of 5 –28,780Family of 6– 32,960Family of 7-37,140Family of 8-41,320Add 4180 for each additional memberUsing the previous chart is your income more or less than the Income level that is indicated? MORE than LESS than OK Question Title * 10. What is your employment status? Full time Part time Seasonal Retired Unemployed OK Question Title * 11. If unemployed what are the barriers that prevent you from being employed? (select all that apply) Criminal Background Drug/alcohol problem Lack of childcare Lack of skills Lack of transportation Language Barrier Learning/developmental disability Other (please specify) OK Question Title * 12. Would you like help with these job-related activities? (select all that apply) Job training Job search Interviewing skills Work clothes None OK Question Title * 13. If you had the opportunity to enroll in job training which of the following would you be interested in: HVAC Electrical/Plumbing Welding Criminal Justice Construstion Fire Fighter/EMT Certified Nursing Aid (CNA) Licensed Vocational Nurse (LVN) Other (please specify) OK Question Title * 14. Do you have minor children living in the home? Yes No OK Question Title * 15. Who provides childcare? Self Family Friends Church Daycare Children stay alone Before and/or after school programs Other (please specify) OK Question Title * 16. Is your child care provider dependable? Yes No OK Question Title * 17. What kind of childcare help do you need? Daycare center Before/after school care Care for child with special needs Evening hours OK Question Title * 18. What is your housing status? Own Rent Staying with friends/family Homeless OK Question Title * 19. Do you have any of the following housing related needs? (select all that apply) Home not safe-structure Housing not affordable Furniture of household goods Handicap access or modifications Mortgage or rent assistance Repairs Utility assistance Neighborhood unsafe None OK Question Title * 20. Do you have reliable phone access? Yes No OK Question Title * 21. Do you have access to internet? Yes No OK Question Title * 22. Do you need any of the following transportation assistance? (select all that apply) Vehicle Child safety seats Driver's license Gasoline Insurance Auto Repairs Vehicle Registration Vehicle inspection Transportation with someone with a disability Bus transportation local Bus transportation out of town OK Question Title * 23. Indicate what type of assistance your family receives (check all that apply) CHIPS Medicaid Medicare Housing Voucher SNAP TANF WIC Utility assistance Rental assistance Other (please specify) OK Question Title * 24. Do you need help with any of these things? (select all that apply) Alcohol/drug abuse Angry control Caregiver support Depression Disability counseling Elder abuse Family conflicts Making decisions/problem solving Parenting classes Goal setting Mental health issues Money management Self-esteem Spouse or child abuse Thoughts of suicide (in the past 6 months) OK Question Title * 25. Do you or someone in your household have any of these health care needs? (select all that apply) Adult with disability AIDS/HIV risk Child with disability Dental care Diabetes Eye/Vision Care General medical care Hearing Care Heart Disease Hypertension Medical Equipment Mental Health care Prescription Medication STD’s (Sexually Transmitted Diseases) Substance abuse treatment Teen Pregnancy Transportation to appointments Other (please specify) OK Question Title * 26. Do you have health insurance or other health care coverage? Yes No OK Question Title * 27. Do you have any of these financial needs or problems? (select all that apply) Earning a living wage Health insurance Car insurance home/renter insurance Assist collecting child support Budgeting Improving credit OK Question Title * 28. Are you a veteran? (if No skip to last question) Yes No OK Question Title * 29. If you are a veteran, are you receiving benefits? Yes No OK Question Title * 30. If you are not receiving benefits do you need help in getting them? Yes No OK Question Title * 31. If you are a veteran or dependent, do you need assistance with any of the following? (Check all that apply) Connecting to Veteran Organizations Disability Education and training Employment Health care Housing Life insurance Medals and records Medical benefits Mental healthcare Pension Reserve and guard Special and limited benefits Transition assistance Transportation VA claim appeals OK Question Title * 32. What have we not asked you about that you feel is important for us to understand your current needs? OK Question Title * 33. What do you think it something that your community does well to provide services to those who are in need? OK DONE