DAIL Community Needs Assessment

Community Needs Assessment Questionnaire

The following questionnaire will only take a few minutes to complete and it will assist in helping people, meeting the community needs, and providing hope. All information will be kept confidential and your name is not required on the questionnaire. THANK YOU FOR YOUR TIME!

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* 1. What is your role in the community? (Please select the best choice which fits your role when completing this survey.)

Community Action Client/Low-Income Resident

Faith Based Organization Representative (Church/Faith Based groups, clubs, councils, association, etc.)

Private Sector Representative/Community Member (for profit, small business, private citizen, etc.)

Community Organization/Partner (local service provider and non-profits)

Educational Institution Faculty/Staff (local adult eds, schools, college and universities)

Health Care Agencies (clinics, health departments, etc.)

Board Member of Community Action Agency

Staff or Volunteer of Community Action Agency

Local Politician/Government/Public Sector Representative (non-profit, government regulated, funding sources, etc.)

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* 2. In which county do you live or represent (for the agency)?

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* 3. What is your gender?

Male

Female

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* 4. What is your age?

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* 5. What is your race?

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* 6. What is your ethnicity?

Hispanic, Latino or Spanish Origins

Not Hispanic, Latino or Spanish Origins

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* 7. What is your education level?

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* 8. What is your Military Status?

Veteran

Active Military

N/A

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* 9. Are you a caregiver?

Yes