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SAMPLE COMMUNITY NEEDS ASSESSMENT SURVEYFOR THE ROSS SERVICE COORDINATOR PROGRAMPart I: Household Information:Are you an adult 18 years or older? (circle one)YesNoAre you the head of household? (circle one)YesNoDoes anyone in your household have a mental or physical disability? (circle one)YesNoPart II: Community/Household Needs:How would you rate the following issues for your household?IssueSerious ProblemModerate ProblemNot a ProblemDoes Not Apply to My HouseholdAvailability of job training opportunitiesAvailability of jobs for adultsAvailability of jobs for youthEducationAvailability of child-care servicesLack of computer/digital literacyCost of livingIncome/wagesDebtFinancial securityAvailability of financial servicesAvailability of financial counselingElderly living assistance (62+)Physical healthMental healthSeeking employment with a criminal recordObtaining a degree/diploma with a criminal recordAvailability of substance abuse servicesNeed for substance abuse treatment What are the things that make it difficult for you or other adults in your household to find and/or keep work? (check all that apply)BARRIER Check All that ApplyNothingNeed affordable childcareCaring for a family member who is sick or disabledDo not speak English wellNeed computer trainingNeed transportationNeed job experienceNeed job trainingNo job opportunitiesDo not have a high school diploma/GEDDo not have a college degreeDisabilityCriminal recordLack of transportationOther – specifyOther – specifyOther – specify Don’t knowNo responseDo you or others in your household have interest in the following? (check all that apply)INTERESTCheck All that ApplyGED/Adult educationVocational trainingIncreasing incomeGetting a jobGetting a better jobComputer trainingSaving moneyEliminating debt2-year college4-year collegeTrade schoolOther (specify)Other - specifyDon’t knowNoneNo responseDo you or another adult in your household have difficulty with any of the following? (check all that apply)SUBJECT/SKILLCheck All that ApplyReadingMathWritingSpeaking EnglishWriting EnglishUsing a computerOther – specifyOther – specifyOther – specify Don’t knowNoneNo responseWhat are the primary health care needs of your household? (check all that apply)HEALTHCARE NEEDSCheck All that ApplyPrimary health carePediatric (child) carePrenatal (pregnancy) careDental careHealthcare education/preventionNutrition and exercise programsServices to help alleviate stress/anxiety/depressionAssistance with daily living for elderly/disabled residentsHealth screening servicesSubstance abuse treatmentSmoking cessation programsDrinking cessation programsTransportation to healthcare servicesOther – specifyOther – specifyOther – specifyDon’t knowNoneNo responseWhat is your gender? (check one)GENDERCheck OneIdentifies as femaleIdentifies as maleOtherWhat is your age (check range)AGE RANGECheck One18-2425-3435-4445-5455-6565 or olderNo response ................
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