Syracuse Housing Authority & Upstate Life Needs Survey
We would appreciate it if you would take a few minutes to complete the following survey. The information will be kept confidential and will be used to assist in community revitalization and addressing community need. The survey should be completed by the head of household or spouse. Thank you for your participation.
Sign in to Google to save your progress. Learn more
Email *
Participants with be chosen at random for a cash reward for filling out and completing the survey. We would like to offer 3 prizes –a $500 gift card, a $250 Gift Card, and a $100 gift card.
*only eligible for completing the survey*
Resident Name
Resident Address
Date of Birth
Disability?
Clear selection
Gender
Marital Status
Race & Ethnicity
GENERAL
What is the primary language spoken in your home? (English, Spanish, other)
 Do you or anyone in your household own a working computer or smartphone?  
Clear selection
Do you have access to the internet?
Clear selection
Do you go on SHA's Facebook page and/or website?
Clear selection
Do you participate in the tenant association, resident council, or any other civic groups?
Clear selection
Would you like to participate in your tenant association?
Clear selection
SERVICES FOR SENIOR & DISABLED RESIDENTS
If you are a senior citizen or a disabled resident, please answer next 3 questions.
Do you have a home health care worker?  If YES, how many hours per day. If NO, would you like to receive this service?
Do you receive Meals on Wheels?
Clear selection
Do you participate in any senior activities?  (specify)
Would you pay $3 for a healthy, nutritious meal once a week?
Clear selection
SERVICES FOR CHILDREN
Do you have any children ages 5 and under living in your household?
Clear selection
How many children ages 5 and under live in your household?
Is your child/children aged 5 and under enrolled in Head Start, Pre Head, or other early education program?
Clear selection
Has your child/children aged 5 and under participated in developmental screenings?
Clear selection
Do you have any children ages 6-18 living in your household?
Clear selection
How many children ages 6-18 live in your household?
Do you have a child/children  that has been diagnosed with a learning disability or other obstacle in learning?
Clear selection
Is your child/children aged 6-18 enrolled in after-school and/or tutoring program? (If yes, specify)
What school(s) do your children attend?
What activities would you like to have available in your neighborhood? (Check all that apply)
Do you need childcare assistance?
Clear selection
EMPLOYMENT & EDUCATION
What is your employment status?
Clear selection
What industry do you work in? (check all that apply)
What is the highest level of education that you completed?
Clear selection
Is anyone in your household currently participating in any job training or adult education programs?
Clear selection
If currently unemployed, what is the greatest barrier to successful employment? Please pick one.
Clear selection
SAFETY
How safe do you feel in your home?
Clear selection
How safe do you feel in your neighborhood?
Clear selection
If you feel unsafe, what are the reasons you feel unsafe? (Check all that apply)
What do you think could improve public safety in your community? (check all that apply)
OVERALL HEALTH
How would you describe your overall health?
Clear selection
Where do you go for routine health care?
Clear selection
When was the last month and year you received routine health care?  Give month/year.  (if none, answer next question)
If no health routine care/check. Why not?
What type of health insurance do you have?
Clear selection
Please specify insurance provider below (if applicable)
Please select the top 3 health issues you face from the list below:
Which of the following statements apply to you? (check all that apply)
Which of the following preventive procedures have you had in the past 12 months?  (check all that apply)
If you are worried about Cancer, what type are you worried about? (Please check all that apply)
If you answered "Other" to the question above, please specify what type(s) of cancer you're worried about.
COVID-19
In the case of a quarantine/isolation, do you have enough food and household essentials (toothpaste, toilet paper, soap, feminine products, etc.)?  
Clear selection
Do you antibacterial soap or other disinfectant cleaners such as bleach, clorox, lysol?
Clear selection
If you have young children, do you have a 7-day supply of baby essentials (formula, baby food, diapers etc.)?
Clear selection
Do you have a 2-week supply of prescriptions, medicines, or other necessary medical supplies?
Clear selection
Are you and/or your school aged children able to do remote learning?
Clear selection
Were you able to pay rent and utilities this month?
Clear selection
Did you lose employment as a result of the pandemic?
Clear selection
Community Planning
Are you satisfied with your current housing?
Clear selection
 If you are satisfied, indicate why:
Clear selection
If you are NOT satisfied, indicate why not?
Clear selection
Are you satisfied with your neighborhood?
Clear selection
If you are satisfied, indicate why:
Clear selection
If you are NOT satisfied, indicate why:
Clear selection
Do you have dependable and safe transportation when you need it?
Clear selection
What is your primary method of transportation?
Clear selection
Are there activities or groups that you like to participate in your neighborhood? (Yes/No) Specify.
Are there existing businesses or services that you would like to see maintained in your neighborhood? (Yes/No) Specify.
Are there any new businesses or services that you would like to see in your neighborhood? (Yes/No) Specify.
 How satisfied are you with the services/programs/activities that are available in your neighborhood?
Clear selection
Additional Comments:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms