Community Needs Assessment Survey

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We are assessing needs of our community for the upcoming year. We desire information from you so that decisions made are based on what is
most important to you. These items are questions that relate to issues in your community. 
Please take a few minutes to complete the survey.
Be assured that your individual answers will remain confidential.
1. Contact Information
4. Please rank the following community issues from Most Important to Least Important:
(1) Being Most Important and (11) Being Least Important
Drag items from the left-hand list into the right-hand list to order them.
Next you will select the item(s) you feel are most important to you from the categories you just ranked.
5. Employment
6. Education
7. Household Expenses
8. Housing
9. Human Services
10. Community
11. Health
12. Environmental
13. Transportation
14. Family
15. Child Care
16. Do you have children 5 years of age or younger living in the home ? *This question is required.
17. Fill out information for each household member.
17. Fill out information for each household member.Relationship ? Age ? Sex ? Race ? Ethnicity ? Education Expectant Mother ? Primary Spoken Language ? Disability ?
You
Member 2
Member 3
Member 4
Member 5
Member 6
Member 7
Member 8
Member 9
Member 10
17. Please select all sources of Public Assistance you receive.
17. Indicate your total family income.
17. Indicate your areas of interest for both child care and other family needs.
17. Do any of your children attend any of these programs ?
17. Are any children in the household currently homeless ?
17. Are any children in the household currently in Foster Care ?
17. Are you currently employed ?
17. Indicate the days and hours you work.
17. Do you currently attend school or some type of training ?
17. Indicate the days and hours you attend school or training.