CAP Needs Assessment
What is your age?
18-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75 years or older
What is your race?
Hispanic or Latino
American Indian/Alaska Native
Other (please specify): _____
What is your current gender identity?
If you prefer another term, please specify: _________________
Decline to answer
What is the highest degree or level or level of school you completed? If currently enrolled, the highest degree received.
No schooling completed
Nursery school to 8th grade
Some high school, no diploma
High school graduate, diploma or the equivalent (for example: GED)
Some college credit, no degree
Trade/ technical/ vocational training
Below is a list of agencies. Please select any of them who are providing aid or support to you and your family.
Second Harvest Food Bank of Coastal Georgia
Union Mission / 211 ( Crisis Situation, Food, Empty Stocking Fund, Rent/ Utilities Assistance)
Chatham Area Transit (CAT)
Goodwill Southeast Georgia
Chatham County Health Department
Curtis B. Cooper Primary Health Care Center
Department of Family and Children Services (DFCS)
Equal Opportunity Authority (EOA)
Georgia Department of Labor (GDOL)
Housing Authority of Savannah
St. Mary's Community Center
The Mediation Center of the Coastal Empire
J.C. Lewis Primary Health Center
Are you currently employed?
I am employed full-time (35 + hours week) (skip to question 7)
I am employed part-time (20 - 35 hours per week) (skip to question 7)
I do side jobs/side hustle, but do not have regular work (skip to question 7)
I am unemployed but looking for work (skip to question 8)
I am not working and not looking for work (skip to question 10)
Other (skip to question 9)
What is the biggest challenge you are facing in keeping your job? (Employed people only)
Finding a job that pays enough
Finding a job close to my home
Finding a job with flexible hours
Finding a job that matches my skill set
Finding a job that has opportunities for advancement
Finding a job with healthcare benefits
How long would you be willing to commute to work when you find a job? (please include time to drop off and pick up children at daycare or any adults for whom you are responsible for their care) (unemployed people only)
Option Less than 10 minutes
More than 1 hour
Employability skills are the key to workplace success. These skills are necessary for the labor market at all employment levels and in all sectors. Which skills do you need to obtain employment?
Applying for a job
Resume Writing and Cover Letter
Job Search Strategies
Email Job Leads
Professional Business Attire
Do you have reliable phone access?
Do you have access to the internet?
Where do you usually use the internet?
At the library
At a friend's home
At a family member's home
What is your zip code?
In what county do you usually stay?
In what city do you usually stay?
What is your relationship/living status (not including children under 18)?
Living alone- no roommates
Living with a roommate who is not your spouse/partner
Living with a partner/spouse
Living with self-sufficient parents, adult children (18+), or other adult family members
Living with a family members (not children) that need personal care
Living in a shelter or temporary housing assistance
Living in a domestic violence facility or other similar program
What is your marital status?
What is the primary language at home?
How many children under the age of 18 are in your household?
How many adults (self not included) reside in your household?
If you use childcare, who typically watches your children?
I don’t use childcare
Family (Grandparent(s), older child, etc.)
Paid in home sitter
Childcare (head start, early learning center)
Family childcare home ( licensed by the state and limited to 7 children)
An after-school program (Boys and Girls, Pryme Time, etc.)
When utilizing childcare outside of the home, what is your biggest challenge?
Finding affordable childcare services
Finding childcare services near my home
Finding quality or reliable childcare services
Finding childcare services near my place of employment
Finding childcare with flexible hours
I don’t use childcare outside of my home
I do not have issues with childcare
Have you ever lost a job because you did not have childcare?
Using the answer from previous question, please select the appropriate number of household members to determine Income level?
Family of 1 - $11,490 (1)
Family of 2 - $15,510 (2)
Family of 3 - $19,530 (3)
Family of 4 - $23,550 (4)
Family of 5 - $27,570 (5)
Family of 6 - $31,590 (6)
Family of 7 - $35,610 (7)
Family of 8 - $39,630 (8)
Family of 9 - $43,650 (9)
Family of 10 - $47,670 (10)
For each additional Family member, add $4,020 (11)
Please indicate if you are currently receiving aid from any of the following assistance programs or have received aid within the past 12 months? (Check all that apply)
SNAP Food Assistance Program
Earned Income Tax credit
Which of these monthly bills do you have? (Check all that apply)
Loans - Payday
Loans - School
Phone - Cell
Phone - House
What types of income do you have? (Check all that apply)
Kindness of strangers
TANF (Temporary Assistance for Needy Families)
Do you have any of the following housing related needs? (Check all that apply)
Home not safe-structure
Housing not affordable
Furniture or household goods
Handicap access or modification
Mortgage or Rent assistance
Other medical related accommodations
Pet friendly environment
Neighborhood not safe
Do you need any of the following transportation related help? (Check all that apply
Child safety seat(s)
Information about bus routes/services
Transportation for someone with a disability
Have you ever lost a job (or not been able to accept a job offer) because of transportation issues?
Regarding transportation, what is the biggest challenge for you and your family?
I do not have transportation issues
Affording a personal vehicle
Maintaining a personal vehicle
Lack of access to public transportation
Public transportation is not reliable
Public transportation is not affordable
Public transportation does not go where I need to go
Are you in need of help with any of these things: (Check all that apply)
Alcohol and drug abuse
Making decisions/problem solving
Planning for the future/ Goal setting
Post-Traumatic Stress Disorder (PTSD)
Spouse or child abuse
Thoughts of suicide (in the past 6 months)
Where do you usually get your food?
Large supermarkets ( Sam's Club, Target, Wal-Mart)
Corner stores or convenience stores
Donations ( family, friends, and church)
Where do you shop for food? (Check all that apply)
Do you need help obtaining food?
Do you or someone in your household have any of these healthcare needs? (Check all that apply)
Adult diagnosed with disability
Child diagnosed with disability
General Medical care
Mental Health care
Substance abuse treatment
Transportation to appointments
Other ( please specify)
Do you have health insurance?
If you have health insurance, who provides your health insurance?
Do you have any of these financial needs or problems? (Check all that apply)
Achieving a "living wage" of income (if you achieve a "living wage" it means you don't need help from social services or government programs)
Need help collecting child support
Need TANF (Temporary Assistance for Needy Families)
Budgeting - getting the most from your money & prioritizing
Have bad credit rating
Have past due bills
Currently in collections
Are you an USA Veteran?
If you are a veteran or dependent, do you need assistance with any of the following? (Check all that apply)
Connecting to Veteran Organization
Education and Training
Healthcare for family members
Medals and records
Mental Health Care
Reserve and Guard
Special and Limited Benefits
Women Veteran Health Services
What have we not asked you about that you feel is important?
Send me a copy of my responses.
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