Community Needs Assessment Questionnaire
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SAMPLE Community Needs Assessment 2019-2020Community Needs Assessment QuestionnaireThe following questionnaire will only take a few minutes to complete and it will assist in helpingpeople, meeting the community needs, and providing hope. All information will be kept confidentialand your name is not required on the questionnaire. THANK YOU FOR YOUR TIME! * 1. What is your role in the community? (Please select the best choice which fits your role when completing this survey.) Agency Client/Low-Income Resident Health Care Agencies (clinics, health departments, etc.) Faith Based Organization Representative (Church/Faith Tripartite Board/Advisory Committee Member Based groups, clubs, councils, association, etc.) Staff or Volunteer of Agency Private Sector Representative/Community Member (for profit, small business, private citizen, etc.) Local Politician/Government/Public Sector Representative (non-profit, government regulated, funding sources, etc.) Community Organization/Partner (local service provider and non-profits) Educational Institution Faculty/Staff (local adult eds, schools, college and universities) * 2. In which county do you live or represent (for the agency)? * 3. What is your gender? Male Female * 4. What is your age? * 5. What is your race? * 6. What is your ethnicity? Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins 1 * 7. What is your education level?* 8. What is your Military Status? Veteran N/A Active Military 2 SAMPLE Community Needs Assessment 2019-2020The following topic areas require that you mark thethree most important needs in each category
Please take the time to review each carefully before making your decision. As always, we valueyour input and feedback
* 9. EDUCATION - Mark the three most important needs
More parents involved in student's education Affordable transportation options to and from school Preschool activities for child(ren) to develop school readiness Affordable high quality childcare options for parent who would skills like to further their education More assessable counseling to prepare students for tech or Increasing the community's knowledge of available education college resources More certificate/degree programs offered locally Other Other (please specify) 10. Please list other agencies/organizations you would be comfortable requesting educational services
* 11. EMPLOYMENT - Mark the three most important needs
More jobs with better pay and benefits Increasing the community's knowledge of available employment resources More training for the types of jobs available in the area Improve the workforce readiness skills of people who are able Affordable transportation to and from job to work Affordable childcare during work hours Affordable adult daycare during work hours Early reinforcement of the values of entering the workforce Other Other (please specify) 12. Please list other agencies/organizations you would be comfortable requesting employment services
3 * 13. HEALTH - Mark the three most important needs
More community focus on preventative healthcare More emphasis on reinforcing healthy eating habits Affordable transportation for health care services More nutritional counseling (one on one and free) Provide more education on maintaining personal hygiene More knowledge of available food resources More payment assistance programs for adult dental, hearing More assistance and resources for victims of domestic and/or vision services violence More access to affordable comprehensive (or primary) health More assistance and resources for victims of elderly abuse care services Other Increasing the commuity's knowledge of available health resources More emphasis on early childhood nutrition education Other (please specify) 14. Please list other agencies/organizations you would be comfortable requesting health services
* 15. HOUSING - Mark the three most important needs
More monthly rental assistance programs More programs to provide free home repair Increased availability of security/utility deposit programs More income based rental housing for disabled and seniors More counseling resources for homeowners More community supports for homeless families More grants to make home ownership and home rehab Other affordable More grants to provide services that reduce energy cost Other (please specify) 16. Please list other agencies/organizations you would be comfortable requesting housing services
4 * 17. INCOME AND ASSET BUILDING - Mark the three most important needs
Anonymous and confidential budget counseling More access to low interest loans More education on how to build assets More information on how to access financial resources Information on how to access free credit counseling Increasing the community's knowledge of available mainstream financial resources Anonymous and confidential savings counseling Other Other (please specify) 18. Please list other agencies/organizations you would be comfortable requesting income and asset building services
* 19. CIVIC ENGAGEMENT - Mark the three most important needs
Increasing the community's skills and knowledge for More knowledge on civic activities leadership development Other More citizenship classes More education on how to join neighborhood associations, community boards, advisory groups or similar organizations Other (please specify) 20. Please list other agencies/organizations you would be comfortable requesting civic engagement services
5 * 21. SUPPORT SERVICES - Mark the three most important needs
Child Support Sexual/Emotional/Physical Abuse Services Legal Services Transportation Services Youth Services Disabled Services Meal Programs In-home services - Seniors Life Skills Programs and Services Senior Centers Substance Abuse Resources Other Elderly Services Other (please specify) 6 SAMPLE Community Needs Assessment 2019-2020Based on the items you selected above, please mark the TOP THREE (3) MAIN SERVICECATEGORIES you feel your community/county needs the most
* 22. OVERALL NEED Employment Health Education Civic Engagement Income and Asset Building Support Services (supporting multiple domains) Housing 23. What do you think is the most important reason you or your community needs Community Action? 7
The following topic areas require that you mark thethree most important needs in each category. Please take the time to review each carefully before making your decision. As always, we …
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