Community Needs Questionnaire
The purpose of this questionnaire is to address the needs, or "gaps" between current conditions and desired conditions or "wants" within the community.
What county do you live in?
How many people live in your home?
Are you male or female?
What is your race/ethnic background?
Do you have people in your home in the following age groups?
Required
What are your sources of income?
Required
What is your household's yearly income?
In the last 12 months, have you or any adult household member (age 18 and over) had problems getting or keeping a job?
If you answered yes to #9, what were the reasons?
Required
In the past 12 months, has your household had problems getting or keeping child care?
If you answered yes to #11, what were the reasons?
Required
Do all of the adults (age 18 and over) in your household have a high school diploma or GED?
What is the educational level of the adults in your household?
Required
In the past 12 months, has your household received emergency help to pay your RENT (this does not include subsidized housing?
In the past 12 months, has your household received EMERGENCY UTILITY assistance? (Emergency utility assistance does not include a payment from the Low-Income Home Energy Assistance Program
Of the following basic needs, please select the needs your household received assistance with in the last 12 months?
Required
Does your current housing situation meet the following needs?
Required
In the past year, has anyone in your household be homeless?
What forms of transportation does your household use?
Required
In the past year, did your household receive food from a food pantry?
Is your household enrolled in the Food and Nutrition Benefit Program (Food Stamps)?
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