Melrose Needs Assessment 2013_English

Introduction

WHEDco, a community development organization in the South Bronx, and the Partnership for a Healthier Bronx at Bronx Health REACH, a community-based coalition committed to improving the health of Bronx residents, are surveying Melrose community members on their needs and interests. We will use this information to design programs to meet those needs and advocate around the community’s pressing concerns. Your responses will be confidential.

Question Title

* I live in zip code

10451

10455

10456

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* I work/go to school in zip code

10451

10455

10456

Question Title

* Please tell us how you feel about your neighborhood. Check one per question.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
My neighborhood is safe	My neighborhood is safe Strongly Agree	My neighborhood is safe Agree	My neighborhood is safe Neutral	My neighborhood is safe Disagree	My neighborhood is safe Strongly Disagree
My neighborhood has affordable housing	My neighborhood has affordable housing Strongly Agree	My neighborhood has affordable housing Agree	My neighborhood has affordable housing Neutral	My neighborhood has affordable housing Disagree	My neighborhood has affordable housing Strongly Disagree
My neighborhood is close enough to buses	My neighborhood is close enough to buses Strongly Agree	My neighborhood is close enough to buses Agree	My neighborhood is close enough to buses Neutral	My neighborhood is close enough to buses Disagree	My neighborhood is close enough to buses Strongly Disagree
My neighborhood is close enough to trains/subways	My neighborhood is close enough to trains/subways Strongly Agree	My neighborhood is close enough to trains/subways Agree	My neighborhood is close enough to trains/subways Neutral	My neighborhood is close enough to trains/subways Disagree	My neighborhood is close enough to trains/subways Strongly Disagree
My neighborhood is clean and well-maintained	My neighborhood is clean and well-maintained Strongly Agree	My neighborhood is clean and well-maintained Agree	My neighborhood is clean and well-maintained Neutral	My neighborhood is clean and well-maintained Disagree	My neighborhood is clean and well-maintained Strongly Disagree
I can get healthy foods in my neighborhood	I can get healthy foods in my neighborhood Strongly Agree	I can get healthy foods in my neighborhood Agree	I can get healthy foods in my neighborhood Neutral	I can get healthy foods in my neighborhood Disagree	I can get healthy foods in my neighborhood Strongly Disagree
I have access to high-quality health services in my neighborhood	I have access to high-quality health services in my neighborhood Strongly Agree	I have access to high-quality health services in my neighborhood Agree	I have access to high-quality health services in my neighborhood Neutral	I have access to high-quality health services in my neighborhood Disagree	I have access to high-quality health services in my neighborhood Strongly Disagree
I know about community events and resources in my neighborhood	I know about community events and resources in my neighborhood Strongly Agree	I know about community events and resources in my neighborhood Agree	I know about community events and resources in my neighborhood Neutral	I know about community events and resources in my neighborhood Disagree	I know about community events and resources in my neighborhood Strongly Disagree
I have access to places to exercise in my neighborhood	I have access to places to exercise in my neighborhood Strongly Agree	I have access to places to exercise in my neighborhood Agree	I have access to places to exercise in my neighborhood Neutral	I have access to places to exercise in my neighborhood Disagree	I have access to places to exercise in my neighborhood Strongly Disagree
I like my neighborhood	I like my neighborhood Strongly Agree	I like my neighborhood Agree	I like my neighborhood Neutral	I like my neighborhood Disagree	I like my neighborhood Strongly Disagree

Question Title

* Please tell us about you/ your family:

	Full time	Part time	Not Working/in School
Are you working?	Are you working? Full time	Are you working? Part time	Are you working? Not Working/in School
Are you in school?	Are you in school? Full time	Are you in school? Part time	Are you in school? Not Working/in School

Question Title

* If you are the primary caretaker of a child/children, please answer the following questions.

If your child/children are younger than 5 years old:

	Yes	No
(i) Do you have childcare for them?	(i) Do you have childcare for them? Yes	(i) Do you have childcare for them? No
If Yes to (i), Is the childcare near where you live/work?	If Yes to (i), Is the childcare near where you live/work? Yes	If Yes to (i), Is the childcare near where you live/work? No
(ii) Are you satisfied with the quality of childcare?	(ii) Are you satisfied with the quality of childcare? Yes	(ii) Are you satisfied with the quality of childcare? No
(iii) Is the childcare affordable?	(iii) Is the childcare affordable? Yes	(iii) Is the childcare affordable? No

Question Title

* If your child/children are in elementary or middle school:

	Yes	No
(i) Are they in an after school program?	(i) Are they in an after school program? Yes	(i) Are they in an after school program? No
(ii) If they are not in an after school program, is it because there was no space in the program?	(ii) If they are not in an after school program, is it because there was no space in the program? Yes	(ii) If they are not in an after school program, is it because there was no space in the program? No
(iii) Are you satisfied with the quality of After School?	(iii) Are you satisfied with the quality of After School? Yes	(iii) Are you satisfied with the quality of After School? No

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* If your child/children are in school (K-12) are you satisfied with the quality?

Yes

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* In general, how would you rate your own health?

Excellent

Very Good

Good

Fair

Poor

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* Do you have a main doctor?

Yes

Question Title

* If yes, I go

Multiple times a year

Once a year

When I really need to

I haven’t been in more than 3 years

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* Are you or anyone in your family dealing with any of these health issues? Please check all that apply.

Diabetes

Heart disease

Asthma

Cancer

Sexually transmitted disease

Substance abuse

Other (please specify)

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* Have you seen a specialist within the last 12 months for any of these health issues?

Yes

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* Typically, how many pieces of fruits or servings of vegetables do you eat a day?

None

1-2

3-4

5 or more

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* During the past 30 days, did you participate in any physical activity or exercise?

Yes

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* Please tell us a few things about smoking:

	Yes	No
I live in a smoke-free building	I live in a smoke-free building Yes	I live in a smoke-free building No
Does anyone smoke tobacco products in your apartment?	Does anyone smoke tobacco products in your apartment? Yes	Does anyone smoke tobacco products in your apartment? No
Would you be interested in living in a smoke-free building?	Would you be interested in living in a smoke-free building? Yes	Would you be interested in living in a smoke-free building? No

Question Title

* What types of business/organizations would you most like to see in your neighborhood? Please select your top 3 only

Grocery store or supermarket

Small grocery, deli or convenience store

Fruit and vegetable vendor (farmer’s market, green cart)

Food establishment (restaurant, bakery, café)

Other retail store (furniture, shoes, clothing)

Pharmacy

Medical facility (health center, doctors office)

Indoor fitness facility or gym

Childcare facility

School (elementary, middle, high school)

College, technical school, or university

Community center or social service organization

Government service (library, post office, courthouse)

Financial service (bank, check cashing, tax preparation)

Other service (laundry, salon, medical, travel)

Police precinct or fire department

Entertainment (movie theatre, arcade)

Cultural institution (performance space, museum)

Religious establishment

Question Title

* What things would you like some help with? Please check all that apply.

Banking and credit

Budgeting

Debt management

Employment/Job training

Starting a business/business training/entrepreneurship

Creative/multimedia training

Continuing education

Computer Training

ESL/Literacy

Re-entry from Prison/Incarceration

Youth education

Child welfare

Counseling

Domestic violence

Public benefits

Emergency food

Housing

Lowering electricity/heat bills

Immigration

Legal issues

Health/dental care

Health/dental insurance

Other (please specify)

Question Title

* Finally, some basic questions about you and your household.

(i) What is your:

Age

Sex

Race

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* (ii) How many people in your household are?

Seniors (over 65)

Adults (18-65)

Children (under 18)

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* (iii) Please select which of the following best describes your annual household income.

Less than $10,000

$10,000-$14,999

$15,000-$19,999

$20,000-$24,999

$25,000-$34,999

$35,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$149,999

$150,000 or higher

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* (iv) Please check all of your major sources of income:

Employment

Public benefits

Pension/Social security

Other (please specify)

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* We would like to be able to follow-up with you. If you are willing, please provide your contact information below.

Name:

Address:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

Name:

Address:

Phone Number:

Email:

Question Title

* I live in zip code

Question Title

* I work/go to school in zip code

Question Title

* Please tell us how you feel about your neighborhood. Check one per question.

Question Title

* Please tell us about you/ your family:

Question Title

* If you are the primary caretaker of a child/children, please answer the following questions.If your child/children are younger than 5 years old:

Question Title

* If your child/children are in elementary or middle school:

Question Title

* If your child/children are in school (K-12) are you satisfied with the quality?

Question Title

* In general, how would you rate your own health?

Question Title

* Do you have a main doctor?

Question Title

* If yes, I go

Question Title

* Are you or anyone in your family dealing with any of these health issues? Please check all that apply.

Question Title

* Have you seen a specialist within the last 12 months for any of these health issues?

Question Title

* Typically, how many pieces of fruits or servings of vegetables do you eat a day?

Question Title

* During the past 30 days, did you participate in any physical activity or exercise?

Question Title

* Please tell us a few things about smoking:

Question Title

* What types of business/organizations would you most like to see in your neighborhood? Please select your top 3 only

Question Title

* What things would you like some help with? Please check all that apply.

Question Title

* Finally, some basic questions about you and your household.(i) What is your:

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* (ii) How many people in your household are?

Question Title

* (iii) Please select which of the following best describes your annual household income.

Question Title

* (iv) Please check all of your major sources of income:

Question Title

* We would like to be able to follow-up with you. If you are willing, please provide your contact information below.

* If you are the primary caretaker of a child/children, please answer the following questions.

If your child/children are younger than 5 years old:

* Finally, some basic questions about you and your household.

(i) What is your: