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COMMUNITY NEEDS ASSESSMENT SURVEY
1.
Name (optional)
*
2.
What is your ZIP code?
(Required.)
*
3.
Age
(Required.)
Under 18
18-24
25-34
35-49
50-64
65+
*
4.
Gender Identity
(Required.)
Female
Male
Non-binary
Prefer not to say
Other (please specify)
*
5.
Race/Ethnicity
(Required.)
Black or African American
Hispanic/Latino
White
Asian
Native American
Pacific Islander
Prefer not to say
Other (please specify)
*
6.
What is your current housing situation?
(Required.)
Stable/permanent housing
Transitional housing
Temporarily staying with others
Unsheltered (living in a car, tent, etc)
Other (please specify)
*
7.
Are you currently receiving any public assistance?
(Required.)
CalFresh(SNAP/EBT)
General Relief
Section 8 or housing assistance
Medi-Cal
Unemployment
None
Other (please specify)
*
8.
Which of the following services would benefit you or your household the most?
(Required.)
Help obtaining ID or vital documentation
Food assistance
Housing assistance
Mental health support
Job application/resume help
Childcare resources
Education/GED/skills training
Legal aid
Transportation assist
Other (please specify)
*
9.
What are the biggest challenges facing your community right now?
(Required.)
*
10.
What are the top 3 priorities you’d like to see addressed in your neighborhood? (Choose up to 3)
(Required.)
Help obtaining ID or vital documents
Food assistance
Housing assistance
Mental health support
Job application/resume help
Childcare resources
Education/GED/skills training
Legal aid
Transportation assistance
Other (please specify)