TCCA Strategy Community Assessment Question Title * 1. Which best describes you and your relationship with TCCA Participant in one or more of TCCA programs Member of the General Public/ Community Other OK Question Title * 2. Are you male or female Male Female OK Question Title * 3. Are you White, African-American, Hispanic, American Indian, or Alaskan Native, Asian, Native Hawaiian, or other Pacific Islander, or other race White (Not Hispanic) African-American Hispanic American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander other OK Question Title * 4. In what zip code is your home located? Example: 00554, or 94305 OK Question Title * 5. What is your age? 18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 or older OK Question Title * 6. Which of the following best describes your household type? Individual Adult female with children Adult male with children Married with children Married with no children Two or more adults with children two or more adults without children Multi-generational- children, parent(s), grandparents(s), etc... other (please specify) OK Question Title * 7. What county do u live in OK Question Title * 8. How many people, by age, currently live in your household? Under 18 18 -64 65+ OK Question Title * 9. Which of he following describes your current sources of household income? (check all that apply) Full-time employement Part-time employment Unemployment benefits Social Security/ SSI Other retirement benefits TANF SNAP/Food stamps Housing subsidy other OK Question Title * 10. Which of the following categories best describes your employment status? Employed, working 40 or more hours per week Employed, working 1-39 hours per week Not employed, looking for work Not employed, NOT looking for work Retired Disabled, not able to work other OK Question Title * 11. Considering the Life Area of HOUSING. Which if the following statements describes your situation best? Homeless or facing eviction Doubled up in another household In temporary, transitional, or substandard housing In stable housing that is safe but barely adequate Housing is safe, adequate, unsubsidized Housing is safe, adequate, subsidized other OK Question Title * 12. Considering the Life area of SAFETY. Which of the following statements describes your situation best? Physical home environment is dangerous; serious injury or harm exists for children and adults Evidence of prior abuse of, and by, household members; child protective services or domestic violence intervention may be needed. Safety level is uncertain and/ or unstable; preventative planning needed. Home environment is safe and stable other OK Question Title * 13. Considering the Life Area of FOOD. Which of the following statements describes your situation best? Must rely on free or low cos food; inadequate or no cooking facilities Receive food stamps but need additional assistance. Difficult to get grocery store. Can meet basic food needs with occasional assistance. Accessible grocery stores have a limited variety and quality limited. Can afford food of choice. Variety of high quality food available in grocery stores. other OK Question Title * 14. Considering the Life Area of PHYSICAL HEALTH. Which of the following statements describes your situation best? Needs immediate medical attention; an emergency/ critical situation An on-going medical need that requires regular treatment and is not currently being managed. An on-going medical need is being treated and managed under the supervision of medical personnel. A variety of resources are available to manage the on-going medical condition. There is no immediate or on-going medical problems. other OK Question Title * 15. Considering the Life Area of HEALTHCARE. Which of the following statements describes your situation best? Have immediate medical needs but no medical coverage No medical coverage; medical care difficult to obtain when needed. Some household members may be in poor health. Some household members do not have health insurance (ineligible, unavailable, or unaffordable). Services unavailable because providers will not accept some types of health insurance, All members are covered by affordable, adequate health insurance; can meet co-pays and deductibles. other OK Question Title * 16. Considering the Life Area if INCOME. Which of the following statements describes your situation best? No income. Rely on donations, charity, family members, etc. to meet basic needs Income adequate to meet basic needs of disposable income reduced by inappropriate, uncontrolled spending. Can manage debts and spending to meet basic needs, however there is no money for emergencies, if they should occur. can meet basic needs and manage debt without assistance Income is sufficient to meet basic needs and well managed enough to create savings and pay for quality of life spending and/or emergencies. other OK Question Title * 17. Considering the Life Area of EMPLOYMENT. Which of the following statements describes your situation best? No household member is employed One or more households has temporary, part-time or seasonal employment; income inadequate to household needs. No benefits (i.e. insurance, retirement, etc...) received from employer. One or more household members is employed full time at, or close to, minimum wage but with few or no benefits. One or more household members is employed full-time at more than minimum wage but with few or no benefits. Household members' income and benefits meet basic needs and enable some discretionary spending. One or more household members has maintained stable employment sufficient to meet family needs for more than a year. other OK Question Title * 18. Considering the Life Area of SUPPORT NETWORK. Which of the following statements best describes your situation best? Family is not part of an active, supportive network. Family support network may exert negative, limiting influences. Family and friends are supportive but lack emotional, social and financial resources to produce change in family well-being. Family and friends provide support that enables the household to make short and long-term changes that increases their well-being. Household reaches out to support services and resources in the community to achieve its goals other OK Question Title * 19. Considering the Life Area of MOBILITY. Which of the following statements describes your situation best? No access to transportation, public or private; may have car that is inoperable. Transportation is available, but unreliable, unpredictable, unaffordable, may have car but no insurance, license, etc. Transportation is available and reliable, but limited and/or inconvenient; drivers are licensed and minimally insured. Transportation is generally accessible to meet basic travel needs Transportation is readily available and affordable; car is adequately insured, mechanically sound. other OK Question Title * 20. Considering the Life Area of LIFE SKILLS. Which of the following statements describes your situation best? Unable to meet basic needs such as hygiene, food, activities of daily living Can meet a few but not all needs of daily living without assistance. Can meet most but not all daily livings needs without assistance Able to meet all basic needs of daily living without assistance. Able to provide beyond basic needs of daily living for self and family. other OK Question Title * 21. Considering the Life Area of CHILD CARE. Which of the following statements best describes your situation best? Child care is needed but none is available/accessible/affordable; child is ineligible Child care is unreliable, substandard, or possibly unsafe. Quality, affordable/subsidized child care available for limited numbers. Reliable child care, affordable without subsidies, is available. Multiple sources of quality, affordable child care are available. other OK Question Title * 22. Considering the Life Area of CHILDREN'S EDUCATION. Which of the following statements describes your situation best? One or more school-aged children not enrolled in school. One or more school-aged children enrolled in school but only occasionally attending classes. One or more school-aged children enrolled in school and attending classes most of the time. One or more school-aged children enrolled and attending classes on a regular basis. other OK Question Title * 23. Considering the Life Area of PARENTING. Which of the following statements describes your situation best? I need more information of better skills so I can deal with safety concerns for my child(ren). I am finding myself in situations where I am not prepared to meet my child)ren)'s needs. I generally think I can meet my child(ren)'s needs, but would really like to know more so I can do better. I feel confident that I am doing a good job with my child(ren). I seem to be more capable and confident about raising my child(ren) than any of my peers. other OK Question Title * 24. Considering the Life Area of LEGAL. Which of the following statements best describes your situation best. One or more households members has current charges and/or pending trial. One or more household members is fully compliant with terms of probation or parole. Parole or probation was successfully completed in past 12 month. No new charges have been filed. No household member has had criminal justice involvement in the past 12 months. No household member has a felony criminal history. other OK Question Title * 25. Considering the Life Area of MENTAL HEALTH. Which of the following statements describes your situation best? One or more household member experience severe difficulty in day-to-day life due to psychological problems; may be a danger to self or others. One or more household member's experiences persistent problems with functioning due to behavior; not a danger to self or others. Only moderate difficulty in functioning; occasional symptoms. Slight impairments to functioning reflect expected responses to life stressors. Good or superior functioning in wider range or everyday problems, concerns and situations. other OK Question Title * 26. Considering the Life Area of SUBSTANCE ABUSE. Which of the following statements describes your situation best? Severe abuse/dependence; institutional living or hospitalization may be necessary. Preoccupation with use and/or obtaining drugs/alcohol; withdrawal or withdrawal avoidance behaviors evident; avoidance or neglect of essential life activities. Use within last 6 months; persistent or recurring social, occupational, emotional, or physical problems related to use; problems have persisted at least one month. Use during last 6 months, but no evidence of persistent of recurrent social, occupational, emotional, or physical problems related to use; no recurring dangerous use. No drug use/ alcohol abuse in last 6 months. other OK Question Title * 27. Of the selections provided below, please choose all of the answer choices you believe are the services that Tri-County Community Action Agency currently offer. Energy/ Utility Assistance Early Childhood Development/Education Homeless Housing Rural Transportation Home Healthcare Food Stamps Section 8 Housing Mental Health Counseling Weatherization and other Housing Repair/Renovation Services Food Shelve/Bank RSVP Family Development/Case Management GED/ High School Diploma Training Christian Outreach and Counseling Special Skills/Vocational Training OK Question Title * 28. What additional services do you feel TCCA, or other organizations, should provide to create the optimal level of assistance for you or others you may know who have needs in your community. Please list as many items as you would like. OK Question Title * 29. Comments. OK DONE