Community

Needs
Assessment
Questionnaire
By completing this survey, you will help towards research of understanding families' resources and needs. You will
be asked to answer survey questions that include education, employment, housing, healthcare and other basic
needs. This will take approxiamtely 15 - 20 minutes of your time.

The benefit of this research is that you will be helping the organizations in your community to better understand our
community needs, the resources available and the services that are still needed. This information will help us to
work together to address services that are needed the most. There are no risks to you for participating in this study,
and no penalty for not participating.

*1. Today's Date:

Date:

*2. What is your age?

*3. How far did you go in School?

I didn't attend school
8th grade or less
Some High School
GED
High School Diploma
Some College
Associate's Degree
Trade School
Bachelor's Degree
Master's Degree
Professional Certification
Doctoral Degree
Other (please specify)

4. Below is a list of agencies. Please select any who are providing you and your family with help?
Hope
ACCESS
Community Action
Cherokee County Public Health
ETMC
The Clothes Closet
The Crisis Center
Living Alternatives
The Mission (People's Church)
Meals on Wheels
Salvation Army
Our Lady of Sorrows Catholic Church
First Methodist Church
The Good Samaritan
River of Life Christian Center
Goodwill
Other (please specify)
*5. Are you able to work?
Yes
No

*6. What is your employment status?

Full time (1)
Not working, retired (5)
Part time (2)
Seasonal (3)
Unemployed (4)

7. If Unemployed, are you currently looking for work?

Yes
No

8. If you are unemployed, please select the reason(s) why below:

Attempting to flee domestic abuse or sexual assault
Criminal Background
Criminal background: Misdemeanor
Criminal background: Felony
Criminal background: Deferred Adjudication
Criminal background: Probation
Criminal background: Awaiting Outcome
Domestic violence/sexual assault victim
Drug/alcohol problem
Lack childcare
Lack permanent address
Lack proper clothing
Lack skills/education
Lack transportation
Lack US documents
Language barrier
Layoff or Downsizing
Learning/developmental disability
Mental health problem
Other health issues
Permanent physical disability
Sexual orientation or gender identity
Temporary physical disability
Unaccompanied youth
Other (please specify)

*9. Would you like help with these job related activities? (Check all that apply)
Career assessment
Career/job training
Job search strategies
Job Interviewing skills
 Resume writing
Career Information options
Work clothes
None

*10. Do you have reliable telephone access?

Yes

No

*11. Do you have access to the Internet?

Yes

No

If No is selected, then SKIP the next question.

12. Where do you usually use the internet? (Check all that apply)
At home
At work
At the library
At a friend's home
At a family member's home
Other (please specify)

*13. What is your Zip code?

*14. In what town do you usually stay?

Alto
Bullard
Cuney
Etna
Gallatin
Jacksonville
New Summerfield
Reese
Recklaw
Rusk
Troup
Wells
Outside of Cherokee County
Other (please specify)

*15. What is your housing status?

Own
Rent
Staying with friends or family
Homeless - streets/car
 Homeless - shelter
Homeless - transitional housing (HUD temporary)
Hotel/motel
Nursing/long term care
Assisted living
Group home
Halfway house
Other (please specify)

*16. Which of the following best represents your racial or ethnic heritage?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Non-Hispanic White or European American
Latino or Hispanic American
American Indian or Alaska Native and White
Asian and White
Black or African American and White
American Indian or Alaska Native and Black or African American
Other Multiple race combinations greater than one percent (please specify)

*17. What language do you speak at home?

English
Spanish
Spanish and English
Other (please specify)

*18. What is your marital status?

Single
Married
Widowed
Divorced
Separated
Living with partner

*19. Do you have minor children? (under 18)

Yes

No

If No is selected, then SKIP the next question.

20. Are you your child(ren)'s primary caretaker?

Yes

No

21. If you have children or other dependents under your care: What is your family situation?
 Single mom
Sindle dad
Two parents
Raising own children and children of others
Raising children of other family members (I am a grandparent, aunt, etc.)
Raising someone else's children, not family
Foster parents
Shared custody
No children, other dependents

22. Who provides your childcare? (or dependent care)? (Check all that apply)
Self
Friends
Family
Church
Daycare
Have to leave children alone
Before and/or after school on campus

If "Self" is selected, then SKIP the next question.

23. Is your childcare (dependent care) provider dependable?

Yes
No

24. Do you need different childcare (dependent care) help?

Yes
No

25. What kind of childcare (dependent care) help do you need?

Daycare center

Before/after school care

Care for child with special needs

Evening hours due to work shift schedule

Other (please specify)

26. Have you ever lost a job because you didn't have dependable child or dependent care?
Yes

No

27. Are you caring for adult children or adult dependents including seniors? (Due to mental or physical
disability)
No
Yes (please specify)

If No is selected, then SKIP the next question.

28. Who provides care for the adult children or adult dependents? (Check all that apply)
 Self
Friends
Family
Church
Daycare
Have to leave elder/senior alone
Able to stay home alone
Other (please specify)

*29. How many people live where you stay?

1
2
3
4
5
6
7
8
9
10
Other (please specify)

*30. 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)

*31. Is your household income "More than" or "Less than" the Income level selected for the number of
household members?
MORE than
LESS than

*32. Which of these monthly bills do you have? (Check all that apply)
Cable/Satellite TV
Car/Transportation
Child Care
Child Support
Credit Cards
Food
 Gasoline
Insurance
Internet
Loans
Loans - Payday
Loans - School
Medical
Mortgage
Phone - Cell
Phone - House
Rent
Utilities
None
Other (please specify)

*33. What types of income do you have? (Check all that apply)
Child support
Employer wages
Family/Friends
Kindness of strangers
No Income
Pension/Retirement
SS
SSI/SSDI
Student grants/loans
TANF (Temporary Assistance for Needy Families)
Unemployment benefits
VA
Other (please specify)

*34. Tell me if you or a household member receive any of these types of assistance? (Check all that apply)
CHIPS - Children's Medicaid
Department of Family and Protective Servcies (DFPS)
Dept. of Assistive and Rehabilitive Services (DARS)
Housing Voucher (Section 8)
Medicaid
Medicare
SNAP (Food stamps)
TANF - Temporary Assistance for Needy Families
Texas Workforce Commission
WIC - Woman, Infants, and Children nutrition assistance
Women’s Health Services
None

*35. Do You, or someone in your home have special needs?

 Yes, me
Yes, a household member
Yes, a household member and me
No

If No is selected, then SKIP the next question.

36. Do you have any of these School/Education related needs? (Check all that apply)
Adult Basic Education
Adult Education (i.e. computer classes)
ARD Assistance (Special Education services at school)
Child's behavior concern
Child's homework/schoolwork concerns
Child's school attendance concerns
Child's standardized exams STARR
Money for tuition. (School, College, Trade School)
Difficulty reading (adult)
Difficulty reading (child)
English as a second language
GED/High School Diploma
Need clothes for school
Obtaining money for school supplies
Other (please specify)

*37. In the past 24 months, has your child had to transfer schools because you moved?
Yes
No
Not Applicable, no school aged child
If YES, how many times?

*38. 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
Repairs
Utility assistance
Neighborhood not safe
NONE
Other (please specify)

*39. Do you need any of the following transportation related help? (Check all that apply)
Car/truck
 Bus tickets ($ for bus)
Child safety seat(s)
Driver's license
Gasoline
Information about bus routes/services
Insurance
Auto repairs
Vehicle registration
Vehicle inspection
Transportation for someone with a disability
NONE
Other (please specify)

*40. Have you ever lost a job (or not been able to accept a job offer) because of transportation issues?
Yes

No

*41. Are you in need of help with any of these things: (Check all that apply)
Alcohol and drug abuse
Anger control
Caregiver support
Couples communication
Depression
Disability counseling
Elder abuse
Family conflicts
Making decisions/problem solving
Parenting classes
Personal problems
Planning for the future/ Goal setting
Post Traumatic Stress Disorder (PTSD)
Self-esteem
Spouse or child abuse
Thoughts of suicide (in the past 6 months)
Trauma
Victimization
NONE
Other (please specify)

*42. Where do you usually get your food?

*43. Do you need information on how to cook food for any of these special diets? (Check all that apply)
Diabetes
Hypertension
Heart Disease
 HIV/AIDS
Gluten free
No, I do not need that information
Other (please specify)

*44. Do you need information on food nutrition?

Yes
No

*45. Do you need to know how to store food so it will last longer?
Yes
No

*46. Do you or someone in your household have any of these healthcare needs? (Check all that apply)
Adult diagnosed with disability
AIDS/HIV risk
Child diagnosed with disability
Dental care
Diabetes
Eye/vision care
General Medical care
Hearing care
Heart Disease
Hypertension
Medical equipment
Mental Health care
Prescription medication ($ for)
Prosthesis
Pulmonary Disease (COPD, Emphysema, Asthma)
STD's (Sexually Transmitted Diseases)
Substance abuse treatment
Teen pregnancy
Transportation to appointments
Sleep problems
NONE
Other (please specify)

*47. Do you have health insurance or other health care coverage?

No
Yes (please specify)

*48. Are there others in your household who are uninsured?

Yes
No, others in household have insurance
No others in my household
Yes (please specify)
49. If you have health insurance, who provides your health insurance?
Self

Employer

Government

Other (please specify)

*50. 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)
Health insurance
Car insurance
Home/Renter insurance
Need help collecting child support
Need TANF (Temporary Assistance for Needy Families)
Budgeting - getting the most from your money & prioritizing
Bank account
Have bad credit rating
Have past due bills
Currently in collections
NONE

*51. Are you a US veteran?

Yes
No

If No is selected, then SKIP to the LAST question.

52. If you are a US veteran, are you receiving veteran's benefits?

Yes
No

53. If you are not receiving veteran's benefits, do you need help getting them?
Yes (1)
No (2)

54. If you are a veteran or dependent, do you need assistance with any of the following? (Check all that
apply)
Connecting to Veteran Organization
Disability
Education and Training
Employment
Health Care
Healthcare for family members
Housing
Life Insurance
Medals and records
Medical benefits
Mental Health Care
Pension
 Reserve and Guard
Special and LImited Benefits
Transition Assistance
Transportation
VA Claim Appeals
Women Veteran Health Services
NONE
Other (please specify)

55. What have we not asked you about that you feel is important?

Done