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Life Needs Assessment
By completing this form you are participating in a life needs assessment that will help us match your needs with organizations that provide services that can help to address them. We may reach out to you if we find a match. You must identify the organization where you are completing the form, but all other questions are optional.
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* Indicates required question
What is the name of the organization where you are completing this form?
*
FOCUS Greater Syracuse
FOCUS Greater Syracuse -- Post-Test
What is your name?
Your answer
What is your Phone Number?
Your answer
What is your email address?
Your answer
What is your address? (example: 431 E Fayette St Syracuse, NY 13202) - Do not add apartment numbers- Zip codes are needed!
Your answer
1.
Do you have long-term housing that you can afford?
Yes
No
Clear selection
2.
Do you feel safe?
Yes
No
Clear selection
3.
Do you have enough food?
Yes
No
Clear selection
4.
Do you have dependable and safe transportation when you need it?
Yes
No
Clear selection
5.
Do you have clothes that are okay for work, school, and for the local weather?
Yes
No
Clear selection
6.
Do you have enough money to meet your needs and pay bills on time?
Yes
No
Clear selection
7.
Do you have public or private health insurance for you and your family?
Yes
No
Clear selection
8. Do you know how to get help if someone in your family needs mental or emotional health care?
Yes
No
Clear selection
9.
Do you have any family members that make you feel unsafe?
Yes
No
Clear selection
10.
Do you have access to good quality childcare if you need it?
Yes
No
Clear selection
11.
Do you know how to get legal help if you need it?
Yes
No
Clear selection
12.
Do you have the skills you need to get the kind of jobs you want?
Yes
No
Clear selection
13.
Do you have a high school diploma or an equivalency diploma (such as a GED)?
Yes
No
Clear selection
14.
Do you know how to get more education if you want it?
Yes
No
Clear selection
15.
Can you say that no one in your household has struggled with addiction in the past year?
Yes
No
Clear selection
16.
Has your home or child been tested for lead?
Yes
No
Clear selection
17.
Do you know how to get help if you or someone in your family has a learning need?
Yes
No
Clear selection
18.
Do you save some money for future needs?
Yes
No
Clear selection
19.
Do you have a stable full-time job?
Yes
No
Clear selection
20.
Do you have sufficient internet and technology access to meet your needs for school, work, and other responsibilities?
Yes
No
Clear selection
21. What is your Race or Ethnicity?
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Native Hawaiian and Pacific Islander
White
Some Other Race
Clear selection
22.
What is your gender?
Female
Male
Nonbinary
Other
Clear selection
23.
What is your annual income?
$0-$15,000
$15,001-$30,000
$30,001-$45,000
$45,001-$60,000
$60,001-$75,000
$75,001-$90,000
More than $90,000
Clear selection
24.
What is your age?
18 or under
19-35
36-55
56 or over
Clear selection
25.
Do you, or any members of your household, have a disability?
Yes
No
Clear selection
26. Now, please consider the needs of your community AS A WHOLE. What do you feel are their TOP 5 most important needs?
Please select 5 needs from the list below that you feel are the TOP 5 needs in the CNY community.
1. Have affordable housing options.
2. Feel safe in the community.
3. Have enough food.
4. Have dependable and safe transportation when needed.
5. Have clothes that are okay for work, school, and the local weather.
6. Have enough money to meet needs and pay bills on time.
7. Have public or private health insurance.
8. Know how to get help if someone needs mental or emotional health care.
9. Have family members that make he/she feel unsafe.
10. Have access to good quality childcare when needed.
11. Know how to get legal help if needed.
12. Have the skills needed to get the kind of jobs desired.
13. Have a high school diploma or equivalency diploma (such as a GED).
14. Know how to get more education if desired.
15. Have household members who have struggled with addiction in the past year.
16. Have had home or child tested for lead.
17. Know how to get help for a family who has a learning need.
18. Have some money saved up for future needs.
19. Have a stable, full-time job.
20. Have sufficient internet and technology access to meet needs for school, work, and other responsibilities.
27. And what are the 3 least pressing needs our community faces?
1. Have affordable housing options.
2. Feel safe in the community.
3. Have enough food.
4. Have dependable and safe transportation when needed.
5. Have clothes that are okay for work, school, and the local weather.
6. Have enough money to meet needs and pay bills on time.
7. Have public or private health insurance.
8. Know how to get help if someone needs mental or emotional health care.
9. Have family members that make he/she feel unsafe.
10. Have access to good quality childcare when needed.
11. Know how to get legal help if needed.
12. Have the skills needed to get the kind of jobs desired.
13. Have a high school diploma or equivalency diploma (such as a GED).
14. Know how to get more education if desired.
15. Have household members who have struggled with addiction in the past year.
16. Have had home or child tested for lead.
17. Know how to get help for a family who has a learning need.
18. Have some money saved up for future needs.
19. Have a stable, full-time job.
20. Have sufficient internet and technology access to meet needs for school, work, and other responsibilities.
28. How aware are you of what our local government is doing to respond to the needs of your community through services and projects?
1. Very aware
2. Somewhat aware
3. Neither aware nor unaware
4. Somewhat unaware
5. Not at all aware
Clear selection
29. How aware are you about what other organizations (not government) are doing to respond to the needs of your community?
1. Very aware
2. Somewhat aware
3. Neither aware nor unaware
4. Somewhat unaware
5. Not at all aware
Clear selection
30. How aware are you about decisions that are made by our local government?
1. Very aware
2. Somewhat aware
3. Neither aware nor unaware
4. Somewhat unaware
5. Not at all aware
Clear selection
31. How aware are you about how your local taxes are being spent?
1. Very aware
2. Somewhat aware
3. Neither aware nor unaware
4. Somewhat unaware
5. Not at all aware
Clear selection
32. How would you describe your ability to get the services you need from local government?
1. Excellent
2. Good
3. Neutral
4. Not Good
5. Poor
Clear selection
33. How aware are you about ways to get involved in your local community?
1. Very aware
2. Somewhat aware
3. Neither aware nor unaware
4. Somewhat unaware
5. Not at all aware
Clear selection
34. How would you describe the opportunities members of your community have to comment on local government decisions and projects?
1. Excellent
2. Good
3. Neutral
4. Not Good
5. Poor
Clear selection
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