Wish List 2018 Grundy County Nonprofit Wish List & Capacity Survey Question Title * 1. Organization Name Question Title * 2. Name of specific program within the organization (please fill out a separate survey for each program if appropriate) Question Title * 3. Program Address Question Title * 4. Website (program or organization) Question Title * 5. Program E-mail: Question Title * 6. Please list your organization/program social networking sites: Facebook ID: Twitter ID: LinkedIn ID: Other: Other: Question Title * 7. Is your organization or program a 501c3 charitable organization? Yes No If not, what is your IRS designation? Question Title * 8. Is your organization/program a unit of local government? Yes No Question Title * 9. Can your organization/program receive charitable donations? Yes No Question Title * 10. Does your organization receive state or federal funding? Yes No Question Title * 11. What are three things your program/organization does really well? 1st 2nd 3rd Question Title * 12. What three things do you wish your program/organization could do better? 1st 2nd 3rd Question Title * 13. What tangible needs does your organization or program have that donors can help provide? Question Title * 14. If money were no object, what would you wish for your organization and/or clients? Question Title * 15. Of that wish list, what items are realistic and achievable with the right resources (other than fixing the State problems or winning the lottery)? Question Title * 16. If donors come for a site visit, what will you show them? Question Title * 17. What volunteer opportunities do you offer - both on-going and special projects? On-going Special Question Title * 18. What services does your organization/program provide? Question Title * 19. Which population(s) does your organization/program serve? Please select all that apply. Early Childhood (birth to 5) Children (ages 6 to 11) Adolescent (ages 12 to 17) Young Adult (ages 18 to 26) Adults (ages 27 to 64) Seniors (ages 65 & up) Families College Students Disabled Veterans/Active Military Homeless Undocumented Individuals Other (please specify) Question Title * 20. How many clients does your program serve in total? Question Title * 21. How many clients does your program serve in Grundy County? Question Title * 22. How do clients pay for your services? Please choose all that apply. Private Insurance Medicaid Medicare Sliding Scale/Self-pay Fixed Price/Self-pay No charge Other Question Title * 23. What is the typical wait time to receive your services? No wait 1-7 days 8-14 days 15-31 days 1-2 months 3-4 months 5-6 months more than 6 months Question Title * 24. Based on your observations and interactions, which age groups struggle to find services in general? Please choose all that apply. Early Childhood (ages 0 to 5) Childhood (ages 6 to 11) Adolescents (ages 12 to 17) Young Adults (ages 18 to 26) Adults (ages 27 to 64) Senior (ages 65 & up) Other (please specify) Question Title * 25. What barriers do clients/residents face that make it difficult to access services and programs in general, not just yours? (check all that apply) lack of insurance distance to services lack of transportation hours of service (lack of evening and weekend hours) client/patient resistance family dysfunction Other (please specify) Question Title * 26. Please list any support groups provided by your organization and/or support groups in the community that you are aware of: Question Title * 27. Does your organization have plans to increase service capacity (additional staff, site, program, etc.) within the next 12 to 18 months? Yes No Unsure Question Title * 28. What are the barriers for service capacity expansion? Please choose all that apply. Lack of capital funding for facility expansion Low Medicaid or State reimbursement rates Governmental rules or regulations preventing expansion Restrictive management of insurance benefits Restrictive management of Medicaid benefits Restrictive management of Medicare benefits No perceived need Instability of State Funding Other (please specify) Question Title * 29. Any last comments we have forgotten to ask that you'd like to share with clients, donors, volunteers, and supporters? Question Title * 30. Is your organization involved in prevention education or other prevention strategies? Yes No Question Title * 31. If you could change one thing about the system for health & social services in Grundy County, what would it be? Done