Community Renewal Team (CRT) 2016 Community Needs Survey

Please help the Community Renewal Team (CRT) identify needs in your community by completing the entire survey. If you have any questions about this survey, please call Jen Chapman at (860) 560-5446. Thank you for your help.

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* 1. What is your zip code?

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* 2. Check whether the following items/services are needs for you or a member of your household.

	Is a Need	Is Not a Need
Food	Food Is a Need	Food Is Not a Need
Clothing	Clothing Is a Need	Clothing Is Not a Need
Housing	Housing Is a Need	Housing Is Not a Need
Utilities (paying for heat, lights, water, etc.)	Utilities (paying for heat, lights, water, etc.) Is a Need	Utilities (paying for heat, lights, water, etc.) Is Not a Need
Employment	Employment Is a Need	Employment Is Not a Need
Education	Education Is a Need	Education Is Not a Need
Transportation	Transportation Is a Need	Transportation Is Not a Need
Child Care	Child Care Is a Need	Child Care Is Not a Need
Infant and Toddler Child Care	Infant and Toddler Child Care Is a Need	Infant and Toddler Child Care Is Not a Need
Income Tax Preparation	Income Tax Preparation Is a Need	Income Tax Preparation Is Not a Need
Budgeting Skills/Money Management	Budgeting Skills/Money Management Is a Need	Budgeting Skills/Money Management Is Not a Need
Health/Dental Care	Health/Dental Care Is a Need	Health/Dental Care Is Not a Need
Home Care Services	Home Care Services Is a Need	Home Care Services Is Not a Need
Behavioral Health Services (mental health counseling, drug/alcohol counseling, etc.)	Behavioral Health Services (mental health counseling, drug/alcohol counseling, etc.) Is a Need	Behavioral Health Services (mental health counseling, drug/alcohol counseling, etc.) Is Not a Need
Legal Services	Legal Services Is a Need	Legal Services Is Not a Need

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* 3. Are you:

Male

Female

Transgender

Male

Female

Transgender

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* 4. What is your age?

Under 17

18 – 23

24 – 44

45 – 54

55-69

70+

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* 5. What is your race? Please choose one:

White

Black or African American

Asian American

Pacific Islander

Two or more races

Other (please specify)

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* 6. What is your ethnicity? Please choose one:

Hispanic, Latino or Spanish Origin

Not Hispanic, Latino or Spanish Origin

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* 7. Military Status

Veteran

Active military

Never served

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* 8. Which best describes your family?

Single-parent family

Two-parent family

Adult(s) (no children)

Grandparent(s) taking care of grandchildren

Other (please specify)

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* 9. How many people live with you?

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* 10. Is anyone 60 years of age or older living in your home?

Yes

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* 11. Is anyone under the age of 5 living in your home?

Yes

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* 12. What is the highest level of education you completed?

Grades 0-8

Grades 9-11/Non-Graduate

High school graduate/GED or high school equivalency

Vocational or trade school training

12 grades + some college (or still in college)

2 or 4-year degree

Graduate degree

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* 13. What is the primary language spoken in your home?

English

Spanish

Other (please specify)

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* 14. Which of the following describes your family’s source(s) of income? (Please check ALL that apply.)

Employment/Work

Unemployment

Temporary Family Assistance (TANF/TFA)

Supplemental Security Income (SSI)

Social Security disability (SSDI)

VA Service Connected Disability Compensation

VA Non-Service Connected Disability Pension

Worker’s Compensation

Pension

Social security

Child Support

Alimony or Spousal Support

State Administered General Assistance (SAGA)

EITC

Other (please specify)

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* 15. Do you or your family receive any of the following non-cash benefits? (Please check ALL that apply.)

SNAP (food stamps)

WIC

LIHEAP (energy assistance)

Housing Choice Voucher

Section 8

Rental Assistance Program (RAP) Certificate

Public Housing

Permanent Supportive Housing

HUD-VASH

Childcare Subsidy

Affordable Care Act (health insurance) Subsidy

Other (please specify)/none of the above/prefer not to answer

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* 16. What is the approximate annual income of your family from all sources? (Check one.)

Less than $15,999

$16,000 to $23,999

$24,000 to $34,999

$35,000 and $54,999

Greater than $55,000

Other (please specify)/prefer not to answer

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* 17. Which of the following best describes your employment situation? (Check one.)

Working full-time

Working part-time

Working seasonal position

Unemployed and collecting

Unemployed and not collecting

Retired

Student

Stay-at-home parent with another working adult in the home

Other (please specify)

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* 18. Do you have health insurance?

Yes

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* 19. What is your housing situation?

Rent

Own

Other (please specify)

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* 20. Have you ever had eviction or foreclosure problems?

Yes

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* 21. Do you own or make payments on a car?

Yes

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* 22. Do you have access to public transportation?

Yes

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* 23. Have you ever claimed the Earned Income Tax Credit (EITC)?

Yes

Don't know

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* 24. Do you or other family members use the following? (Please check all that apply.)

Internet

Working cell phone with annual contract

Pre-paid or "pay as you go" cell phone

Working land-line phone

Cable/dish television

Daily or weekly newspaper

Other (please specify) or None of the above

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* 25. Which CRT programs have you used in the past year? (Please check all that apply.)

Behavioral Health Services

Energy Services

Weatherization

Food Bank

Employment and Training

Head Start

Housing and Shelter

Eviction Prevention

Senior Services

Individual Development Accounts (IDA)

Case Management

Youth Services

Veteran Services

State-Administered General Assistance (SAGA)

Other (please specify)

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* 26. How would you rate your satisfaction with the program or programs in which you have participated?

Poor

Fair

Excellent

Poor

Fair

Excellent

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* 27. Since participating in CRT services/programs, are you better at meeting your own needs?

Yes

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* 28. Since participating in CRT services/programs, are you better at meeting your family's needs?

Yes

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* 29. Have you or a family member ever needed a service but found it was unavailable in our area? If so, please describe below.

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* 30. Are you aware of a community issue that is not being addressed? Please describe it below.

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* 31. If you have any further comment or concern, please let us know in the space below.

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* 32. Please leave your contact information:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number