Community Solutions CDC Community Needs Assessment
To better cater our programs and services, please complete this simple survey. All information collected is CONFIDENTIAL
Male, Female or Other
Middle Eastern Descent
What is your current age?
Married, Single or Divorced
Number of individuals in your household
Employed, Unemployed or Disabled
Highest Level of Education Completed
Less than 9th grade
Less than High School Diploma
High School Diploma or Equivalent
Professional Degree or License
Do you utilize public transportation (SEPTA)?
Sometimes (own other mode of transportation)
Annual Household Income
Less than $12,000
Are you a registered voter?
Do you receive any form of government assistance? (This can include SNAP, SSI-DI, LIHEAP or Section 8)
Do you feel that you have safe & affordable housing in your community?
Do you own or rent your home?
Do you have school age children in your household?
If you have a school age child in the home, do they attend Public, Charter, or Private School?
Private (including Catholic)
Are you satisfied with the local school and recreational facilities options available to your children in the community?
How often do you or your children utilize your local recreational center?
Once a month
Do you feel that your community is safe and meets the health and welfare needs of your family?
Do you feel you have access to fresh, healthy, affordable foods in your community?
Do you do most or all of your grocery shopping locally within the following distances
Less than 1 mile
Greater than 5 miles
How often do you go grocery shopping?
Once a month
What is your monthly grocery budget?
Less than $100
Which local grocer do you utilize?
Brown's Family Shoprite (52nd and Parkside)
Fresh Grocer @ 56th & Market
Save A Lot @ Progress Plaza (57th Vine Street)
Save A Lot @ 56th & Lancaster Avenue
Cousin's Family Market (55th & Girard Avenue)
Brown's Family Shoprite (66th & Haverford Avenue)
Brown's Family Fresh Grocer (Belmont & Parkside Avenue)
Check all of the items that are normally on your grocery list
Meat (Beef, Lamb)
Poultry (chicken, turkey)
Dairy (milk, butter, cheese)
Fresh Produce (fresh fruits & vegetables)
Canned Goods (vegetables, meats, fruit)
Breakfast Items (Cereal, Oatmeal, Pop Tarts, etc)
Snack food items (Chips, Cookies, Candy etc)
Sweetened Beverages (Soda, Diet Soda, Tea, Juice, etc)
Dry Goods/Pantry Items (Rice, Pasta, Sauce, etc)
What would you consider the most pressing concerns in your community? Check all that apply
Access to healthier food options
Improved Public Schools
More/Better School Options (Charter Schools)
Improved Recreational Facilities
Improved/more transportation options
More Affordable Housing
More local employment opportunities
Access to more financial services (Banks, Insurance Agencies, Mortgage Providers)
Improved relations with local police district/more visible cooperation
Less nuisance bars/entertainment options (Stop & Go's, etc.)
Would you like to receive information from Community Solutions on programs and services available?
If you would like to receive information from Community Solutions, please provide your email address
If you would like to receive information from Community Solutions but do not have a valid email address, please provide your Name and mailing address
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service