Copy of Community Action Agency Survey 2024
1.
Community Sector (Please select one)
Low Income
General Public
Other (please specify)
2.
Gender
Male
Female
Other (please specify)
3.
In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)
4.
How many people live in your household?
1-2
3-5
6-9
10+
5.
Household Type (please select one)
Two adults, no children
Single
Single Parent (mother)
Single Parent (father)
Other (please specify)
6.
Age
0-17
18-24
25-34
35-44
44-54
55-64
65+
7.
Number of children under the age of 18?
1-2
3-4
5-6
7+
8.
Number of seniors in your household age 60 or older?
1
2
3
4+
None of the above
9.
Ethnicity?
Hispanic or Latino
Non-Hispanic or Latino
10.
What is your race? (Please select all that apply.)
American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Native Hawaiian
White / Caucasian
Multi-Race
Prefer not to answer
Other (please specify)
11.
What is the highest level of school that you have completed?
K-8th Grade
9th-12th Grade (did not graduate)
High school diploma or GED
12+ some college or post-secondary school
2-4 year college degree
12.
Annual household income range?
Under $7,000
$7,001-$14,000
$14,001-$21,000
$20,001-$28,000
$28,001-$35,000
$35,001-$42,000
$42,001-$56,000
$56,001 or higher
13.
Is anyone in your household considered disabled (mentally or physically)?
Yes
No
14.
Is anyone in your home a veteran?
Yes
No
15.
What technology do you have in your home?
Telephone
Cellphone
Computer, Laptop, Tablet
None of the above
16.
Do you have reliable internet access at your home?
Yes
No
17.
What is your current living situation?
Homeowner (house, condo, trailer, or other home)
Rental (house, apartment, trailer or room)
Someone else's house, apartment, trailer or room
Homeless (shelter, street/outdoors, park)
Transitional Housing
Sober living house
Other (please specify)
18.
EDUCATION
I need help with...... (check all that apply)
Improving my ability to read
Improving my ability to speak English
Assisting someone in my family to get their GED or completing high school
Learning a trade or vocation (for myself or someone in my household)
Finding and/or enrolling in college (for myself or someone in my household)
Finding activities for my child to help them get ready for school
Developing parenting skills to support my child (such as effective discipline, setting limits, managing conflict)
Finding more activities for my child outside of school hours (such as afterschool and summer programs)
Securing childcare for my child when I am at school
Helping my child with their classroom behavior
Other (explain)
19.
EMPLOYMENT
I need help with...... (check all that apply)
Securing or obtaining new ID, birth certificate, or copy of social security card
Finding a job (such as assessing online job board, job fairs)
Finding a job that pays a living wage
Securing a job (such as resume writing, interview coaching
Getting the tools, equipment or clothing needed for my job
Having reliable transportation to and from work
Caring for my family and children while I am working (such as childcare)
Developing the skills and values to be successful at work
Finding employment that will hire someone with a criminal record
Exploring career opportunities beyond the ones i know
Receiving benefits/assistance and also maintaining or advancing in my job
Other (explain)
20.
HOUSING
I need help with...... (check all that apply)
Paying my rent or mortgage
Paying for utilities
Paying for security deposit
Learning about and accessing homeownership assistance programs and services
Learning about and accessing home repair services
Learning how to reduce my household energy costs
Finding and accessing more safe and affordable housing
Learning about my rights as a renter and homeowner
Other (other)
21.
HEALTH
I need help with...... (check all that apply)
Getting to and from healthcare services (such as medical appointments)
Taking care of my family's dental health (such as finding a dentist, paying for services)
Taking care of my family's hearing needs (such as getting hearing tests and hearing aids)
Taking care of my family's vision needs (such as getting eye tests, eyeglasses)
Getting health care and having a primary care provider
Getting affordable health insurance
Making sure my family's has healthy eating habits
Learning more about available food resources (such as food pantries and food assistance programs)
Learning about and accessing resources to care for an aging parent
Accessing mental health care for myself or another adult (such as counseling, substance abuse treatment)
Getting special needs services and resources for my child
Paying for prescription medications
Access to telehealth services
Other (explain)
22.
INCOME AND ASSET BUILDING
I need help with...... (check all that apply)
Making and managing a household budget
Learning how I can use credit successfully and improve my credit score
Learning how I can best save money
Learning how I can best protect my money and prevent from being scammed
Getting other legal advice and counsel
Other (explain)
23.
Are there any other comments about community needs you would like to share?