Cherokee At Large Community Needs Assessment Survey
The Cherokee Nation At-Large Mutual Aid is a new non-profit 501c3 organization conceived by Councilman Johnny Kidwell to create a pathway for bringing services to Cherokee At-Large residents. We ask you to complete this needs assessment survey to help us identify needs and set goals and priorities. Your responses are anonymous. If you would like to be added to our mailing list, please email contact information to dsscott@sageways.com. Wado for your help and participation.
Please complete just one survey per household.
1.
Do you or anyone in your family have a Cherokee Nation tribal registration number?
Yes
No
2.
In what state do you live?
3.
In what county do you live?
4.
What is your zip code?
5.
How many people live in your household?
6.
What are their ages?
1
2
3
4
5
5 or younger
1
2
3
4
5
6 to 18
1
2
3
4
5
19 to 54
1
2
3
4
5
55 to 64
1
2
3
4
5
65 and older
1
2
3
4
5
7.
What are the sources of income or support for your household? (Check all that apply)
Salary from a job
Social Security Income
Income from pension/retirement/savings
Veterans' Administration
Social Security Disability Insurance
Medicare
Medicaid
Food assistance program
Utility assistance
Rental assistance
Other (please specify)
8.
What best describes your annual household income?
$0 to $15,000
$16,000 to $30,000
$31,000 to $45,000
$46,000 to $60,000
$61,000 to $75,000
$76,000 and greater
Prefer not to answer
9.
Is anyone in your household a military veteran?
Yes
No
10.
Is anyone in your home a caregiver for an aging or disabled household member?
Yes
No
11.
Are any of the following an issue or concern for your household?
No, not ever an issue
Yes, sometimes an issue
Yes, always an issue
Food insecurity
No, not ever an issue
Yes, sometimes an issue
Yes, always an issue
Housing/Shelter insecurity
No, not ever an issue
Yes, sometimes an issue
Yes, always an issue
Lack of transportation
No, not ever an issue
Yes, sometimes an issue
Yes, always an issue
Needing help with utilities
No, not ever an issue
Yes, sometimes an issue
Yes, always an issue
Needing help making your home safe for aging household members
No, not ever an issue
Yes, sometimes an issue
Yes, always an issue
Other (please specify)
12.
Has anyone in your household been diagnosed with any of the following? (Check all that apply)
Diabetes
Hypertension
Heart disease
Arthritis
Dementia/Alzheimer's
Depression/Anxiety
Another mental health condition
Substance/Opioid/Alcohol addictioin
Cancer
Hearing loss
Vision loss (blindness)
Another medical condition
Other (please specify)
13.
If you have health problems that have not been addressed, please say why.
Don't want to know
No insurance
No funds for medication/treatment
No transportation
No available providers
No appointments available
Other (please specify)
14.
Does anyone in your household: (Check all that apply)
Experience frequent falls
Have trouble walking up/down stairs
Have trouble with Activities of Daily Living (dressing, bathing, eating, etc.)
Use a walker or wheelchair
Experience isolation or loneliness at times
15.
Are you active with a Cherokee At-Large Community Organization?
Yes
No
16.
If yes, please say which one(s).
17.
What are the community's needs, based on your experiences with your Cherokee at-large community?
18.
What are the community's strengths based on your experiences with your Cherokee at-large community?
19.
How likely is it that you would contribute to a mutual aid organization to help other at-Cherokees? (Check only one)
It is likely I would help with a one-time donation.
It is likely I would help with regular monthly donations.
It is likely I would help with donations in the future, but not right now.
It is unlikely that I would contribute to this type of organization.
20.
Feel free to use this space to share your opinions, thoughts, or suggestions about a mutual assistance organization to serve at-large citizens.
Wado!