CAP Needs Assessment
Email address *
Today Date *
What is your age? *
What is your race? *
What is your current gender identity? *
What is the highest degree or level or level of school you completed? If currently enrolled, the highest degree received. *
Below is a list of agencies. Please select any of them who are providing aid or support to you and your family. *
Are you currently employed?
What is the biggest challenge you are facing in keeping your job? (Employed people only) *
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) *
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? *
Do you have reliable phone access?
Do you have access to the internet?
Where do you usually use the internet?
What is your zip code? *
Your answer
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)? *
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?
When utilizing childcare outside of the home, what is your biggest challenge?
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? *
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)
Which of these monthly bills do you have? (Check all that apply)
What types of income do you have? (Check all that apply)
Do you have any of the following housing related needs? (Check all that apply)
Do you need any of the following transportation related help? (Check all that apply
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?
Are you in need of help with any of these things: (Check all that apply)
Where do you usually get your food?
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)
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)
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)
What have we not asked you about that you feel is important?
Your answer
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