ICAA Community Needs Assessment Survey - 2019
Would you like to have input about needs in your community? As a resident of your community, you are in a great position to help identify needs and potential solutions! Your responses are important and will be used to help better understand community needs and improve ICAA's outreach and services. (Your answers, should you choose to participate, are anonymous, and we believe you cannot be identified by your answers.)
What county is your primary residence located in?
What is your age? (Must be at lease 18 years old to participate.)
Your answer
What is your gender?
What is the highest level of education you have completed?
What is your ethnicity?
Do you speak a language other than English as your primary language at home? (If yes, which language?)
Your answer
Which employment status best describes you? (Check all that apply)
What is the total income of adults living in your household?
What are your household's sources of income? (Check all that apply.)
How many people in each of the following age categories live in your household?
1
2
3
4
5
6+
0-17 years
18-24 years
25-34 years
35-44 years
45-54 years
55-64 years
65+ years
How many people in your household (18 or older) currently fall into one of the following categories?
1
2
3
4
5
6+
Employed full time
Employed part time/seasonal
Not employed
Disabled
Retired
Student
What category best describes your household (please choose only one)?
What best describes your current housing situation?
Have you been homeless?
Do you or your family receive housing assistance (Section 8 or subsidized housing)?
Have you experienced any of the following housing problems during the last 12 months? (Check all that apply.)
Please rate the following housing concerns as they relate to your household.
Not a concern
Slight concern
Somewhat a concern
Moderate concern
Extreme concern
Paying for rent
Dealing with landlord issues
Making house (mortgage) payments
Paying for home repairs
Paying for utility bills
Getting insulation and/or weatherization
Finding safe, affordable housing
Paying property taxes
Buying a house
Finding emergency shelter
Please check all of the following that apply to you regarding transportation.
Please rate the following transportation concerns as they relate to your household.
Not a concern
Slight concern
Somewhat a concern
Moderate concern
Extreme concern
Buying a reliable vehicle
Obtaining a driver license
Paying for fines
Paying for auto service/repairs
Paying for auto insurance
Paying for gas/diesel
Having a way to get to work or school
Finding public transportation
Please rate the following legal concerns as they relate to your household.
Not a concern
Slight concern
Somewhat a concern
Moderate concern
Extreme concern
Child support payments
Bank foreclosure on home
Bankruptcy
Domestic abuse
Creditors/debt collection
Eviction
Access to public benefits programs
Access to government health insurance
Access to veteran's benefits
Do you currently have health insurance? If no, please describe why not.
Your answer
What types of health insurance do you or someone in your household have? (Please check all that apply.)
Which of the following stops you from seeing a doctor when you have a health need? (Check all that apply.)
Which of the following stops you from seeing a dentist when you have a dental need? (Check all that apply.)
Which of the following stops you from seeking help when you have a mental health need? (Check all that apply.)
How concerned are you about your family or friends' mental health?
How concerned are you about your own mental health?
How often in the past month did you or a member of your household experience mental health problems that interfered with your usual daily activities?
Please answer the following statements about you and/or your household relating to health care.
Yes
No
In the past year, I/someone in my household has not filled medical prescriptions because I/we couldn't afford to
In the past year, I/someone in my household has not bought medically necessary items (glasses, hearing aids, etc.) because I/we couldn't afford to.
In the past year, I/someone in my household has gone to a free clinic to see a doctor.
I/my household maintain a healthy diet/proper nutrition (vegetables, fruits, lean protein, etc.)
I/my household participate in regular exercise (at least 30 minutes of exercise 3 times a week).
I/my household obtain adequate rest and relaxation.
Do you or a member of your household use any of the following substances? Remember, your responses are anonymous! (Check all that apply.)
Please answer the following statements about you and/or your household relating to money and education.
Yes
No
Unsure
I have an account at a bank or credit union (e.g. checking, saving, CD, IRA, etc.)
My family and I receive the Earned Income Tax Credit (refundable federal or state income tax credit)
I have money in savings available to me
I need help learning how to budget my monthly expenses
I need help balancing my checkbook
I need help understanding my credit report
I, or someone in my household needs additional education to earn a living wage (support your household
without government benefits)
I, or someone in my household needs assistance with basic literacy (reading, writing, and/or math)
I, or someone in my household needs assistance learning basic computer literacy skills.
I, or someone in my household needs assistance learning to speak English.
Do you have any of the following in your household? (Check all that apply.)
Please answer "yes" or "no" to each statement regarding food and nutrition as it relates to your household.
Yes
No
In the past year, there was a time when I/we could not afford to provide the household with enough food.
In the past year, I/we have been able to afford to buy fresh fruits and vegetables every week.
In the past year, I/we have purchased food from farmer's market.
In the past year, I/we have used a community food program (food pantry, free meals, etc.)
In the past five years, I/we have used the FoodShare (food stamps, SNAP) program.
I/we would like to learn how to prepare healthy meals.
I/we garden to grow food.
I/we would be interested in learning to garden to grow food.
Please identify the top three areas of need which have had the biggest impact on you/your household over the past year. (Please check only 3 options.)
What have we not asked you about you/your household/your community needs that you feel is important?
Your answer
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