1999 Basic Needs Assessment


 

Appendix: Community Survey Form

Community Needs Survey June - July 1999

A. Please tell us about yourself:

1. Where do you live? Neighborhood _________________

Zip code _____________________

Precinct (Circle one) 1 2 3 4

2. How long have you lived in this community/neighborhood?

  • Less than 1 year
  • 1 to 3 years
  • More than 3 years and up to 5 years
  • More than 5 years (How many years? ______)

3. How many people live in your household? Number of people ________________

Number of adults _______ Number of children under the age of 18 _________

4. What is your race/ethnicity? African-American Hispanic Caucasian Other

5. What is your gender? Male Female

6. Do you have a disability? Yes No Please describe: ________________________

7. Are you currently? (Check all that apply)

  • Employed (full-time)
  • Employed (part-time)
  • Unemployed
  • Retired
  • Homemaker (full-time)
  • Student (full-time)
  • Student (part-time)

8. What is your households annual income? (Check one)

  • $0 - $1,000
  • Over $2,000 and up to $5,000
  • Over $5,000 and up to $12,000
  • Over $12,000 and up to $19,000
  • Over $19,0000 and up to $26,000
  • Over $26,000 and up to $36,000
  • Over $36,000 and up to $50,000
  • Over $50,000

9. Do you? (Circle one) Rent/Lease Own Living with family/friends Not have a home

B. Child Care

1. Do you have or need child care? Yes No

If yes, please answer the questions in this section. If no, please go to Section C.

2. How many children do you have in need of child care? Number of children _______

3. What type of child care do you have?

  • Do not have any care at this time
  • Licensed day care center
  • Non-licensed day care center
  • Preschool
  • Friend
  • Adult relative
  • Child/teenager relative
  • Baby sitter

4. How much do you pay for child care per month?

  • Less than $50 and up to $100
  • Over $100 and up to $250
  • Over $250 and up to $350
  • Over $350 and up to $450
  • Over $450 and up to $550
  • Over $550

5. How many hours does your child stay in child care per week? _________

6. What is the quality of the child care? (Circle one) Poor Average Good Excellent

7. How much time does it take to go from your home to child care? (Circle one)

10 to 20 minutes 30 minutes 45 minutes 1 hour More than 1 hour

8. How do you take your children to child care?

Bus Car Walk Friend or relative drives Bicycle Other ____________

C. Adult Care

1. Do you have or need day care for your parents or older relatives? Yes No

If yes, please answer the questions in this section. If no, go to Section D.

2. How many parents/older relatives do you have who need day care? Number _______

3. What type of care do you have for your parents/older relatives?

  • Do not have any care at this time
  • Senior citizens activity center
  • Licensed nurse/ home health aid
  • Respite home
  • Friend
  • Adult relative
  • Child/teenager relative

4. How much do you pay for day care for your parents/older relatives per month? (Check one)

  • Less than $50 and up to $100
  • Over $100 and up to $250
  • Over $250 and up to $350
  • Over $350 and up to $450
  • Over $450 and up to $550
  • Over $550

5. How many hours do your parents/older relatives receive care per week? _________

6. What is the quality of the care? (Circle one) Poor Average Good Excellent

7. How much time does it take to go from your home to adult care? (Circle one)

10 to 20 minutes 30 minutes 45 minutes 1 hour More than 1 hour

8. How does you parent/relative travel to adult care? (Circle one)

Bus Car Walk I drive Friend or relative drives Other_____________

D. Transportation

1. How often do you ride the bus?

  • Almost every day
  • At least once a week
  • At least once or twice a month
  • Once or twice a year
  • Never

2. If you hardly ever ride the bus, why? (Check all that apply):

  • No buses are near my: (Check all that apply)
    • house
    • workplace
    • childcare
    • school
    • doctor/dentist/clinic
    • friends
    • shopping
    • sports activities
    • movies/shows

      Takes too long

    • Costs too much
  • Too many transfers needed
  • Too much hassle

3. What would make it easier for you to ride the bus?

  • A bus route in my neighborhood
  • Less expensive
  • More direct routes
  • I dont plan to ride the bus
  • Other ___________________________________________

4. Do you have any of the traffic problems listed below in your area?

  • Speeding through neighborhood streets
  • Children cant cross the street safely
  • No place to cross the street safely (Pedestrian crossing lights)
  • Too much noise from traffic
  • No traffic problems
  • Other _________________________________________

E. Community Services

1. Have you ever needed:

2. Where did you go to get it?

(Please list the names of the agencies or places where you went)

3. How many times did you need this service in the last year?

4. Did the service meet your needs?

(Circle one)

Health care

 

Yes

Sort of

No

Money for rent

   

Yes

Sort of

No

Money to pay utilities

   

Yes

Sort of

No

Youth services

   

Yes

Sort of

No

Food

   

Yes

Sort of

No

Job training

   

Yes

Sort of

No

Help finding a job

   

Yes

Sort of

No

Clothes

   

Yes

Sort of

No

Please answer the questions in the table below.

1. Have you ever needed:

2. Where did you go to get it?

(Please list the names of the agencies or places where you went)

3. How many times did you need this service in the last year?

4. Did the service meet your needs?

(Circle one)

Housing

 

Yes

Sort of

No

Housing repairs such as: (Check all that apply)

Heating/cooling

   

Yes

Sort of

No

Weatherization

   

Yes

Sort of

No

Access for disabled

   

Yes

Sort of

No

Wastewater & sewage systems

   

Yes

Sort of

No

Health and safety repairs to home

   

Yes

Sort of

No

Legal aid

   

Yes

Sort of

No

Other _____________________________    

Yes

Sort of

No

5. What suggestions do you have to would make it easier for you to get the services you need?

6. What time would you like each service (listed below) to be open to the public?

Service

Hours needed to be available

(Check all that apply)

Child care
  • 8am-5pm weekdays
  • 8am-12pm weekends
  • 8am 8pm weekends
  • 8am 5pm weekends
Health care/doctor appointments
  • 8am-5pm weekdays
  • 8am-12pm weekends
  • 8am 8pm weekends
  • 8am 5pm weekends
Money for rent & housing
  • 8am-5pm weekdays
  • 8am-12pm weekends
  • 8am 8pm weekends
  • 8am 5pm weekends
Food
  • 8am-5pm weekdays
  • 8am-12pm weekends
  • 8am 8pm weekends
  • 8am 5pm weekends
Clothes
  • 8am-5pm weekdays
  • 8am-12pm weekends
  • 8am 8pm weekends
  • 8am 5pm weekends
Job training or finding a job
  • 8am-5pm weekdays
  • 8am-12pm weekends
  • 8am 8pm weekends
  • 8am 5pm weekends
Emergency housing
  • 8am-5pm weekdays
  • 8am-12pm weekends
  • 8am 8pm weekends
  • 8am 5pm weekends

Other

_______________________

  • 8am-5pm weekdays
  • 8am-12pm weekends
  • 8am 8pm weekends
  • 8am 5pm weekends

F. Volunteering

1. Are you willing to volunteer in your community? Yes No

If yes, please answer the questions in this section.

2. Please indicate the volunteer services you are willing to give to the community.

  • Job training
  • Answering the Telephone
  • Teaching Various Prevention Classes
  • Running Errands
  • Working with Children
  • Working with Seniors
  • Teaching English as a Second Language Classes
  • Teaching Healthy Nutrition Classes
  • Teaching Preventative Health Classes
  • Other______________________

3. May we contact you to discuss the services you are willing to volunteer?

Name____________________________

Telephone Number_________________

Thank you for completing this survey.

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