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Raleigh County Family Resource Network
Needs Assessment Survey
In an effort to better meet the needs of your community we ask that you please complete this survey. If you receive more than one copy of the survey, only one needs to be completed per household. We appreciate your assistance in helping us identify your community's needs. Should you have any questions please call (304)255-3764.
Although the survey is strictly confidential, you may leave blank any question(s) you do not feel comfortable answering.
1. Participant Information (Please check appropriate boxes)
Five Digit Zip Code
Age:
Under 18
18-24
25-44
45-64
65 and over
Sex:
Female
Male
Marital Status
Single
Married
Divorced
Widowed
Other
How many adults (18 and older) including yourself live in your household?
How many children (17 and younger) live in your household?
Ages of the children: ex. write (1,17,8)
What is your ethnic origin?
African American
Asian/Pacific Islander
Caucasian/White
Hispanic/Latino
Indigenous/ Native
Other
Total Annual Household Income:
$15,000 or less
$15,001-$20,000
$20,001- $30,000
$30,001-$45,000
$45,001-$60,000
$60,001-$90,000
$90,001 or more
What is your education level?
Less than high school
High School Diploma/GED
Some College
2-4 Year College Degree
Some Graduate Level
Graduate Degree
Are you registered to vote?
Yes
No
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2. Health
What is your health status?
Excellent
Good
Fair
Poor
Other (I don't know, managing, in process of knowing, etc.)
In a few sentences, please describe your health:
Do you exercise?
Not at all
Sometimes
Often
Almost Everyday/Everyday
Tobacco Use:
Never smoked
Ex-Smoker
Smoke 1 or less pack daily
Smoke 2 or more pack daily
Smoke pipe/ cigar regularly
Use smokeless tobacco
Vape
Other
Do you have health insurance (check all that apply)?
Private
Receive through employment
Medicaid
Medicare
CHIP (Children's Health Insurance Program)
Children covered but adults are not
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3. Needs and Services
Which of the following areas do you see as the five greatest needs/concerns for you, your family, or community? (Check only five)
Personal Safety
Vocational Training
Mental Health
After School Programs
Home Repair
Teen Violence
Domestic Violence
Recreation Activities
Child Abuse
Senior Citizen Care
School Dropout
Housing
Employment
Job Skills
Parenting Support
Food and Clothing
Transportation
Illegal Drugs/ Alcohol
Teen Pregnancy
Child Daycare
Physical Health
Adult Education/ GED
Nutrition Access/ Info
Budgeting/Finance Skills
Education
Environment
Crime
Other
Comments on those needs or concerns:
What type(s) of services do you or your family receive?
Do not receive public assistance
Food Stamps
Free/ Reduced School Lunch
HUD (Housing Assistance)
Child Care Assistance
Vouchers of any kind
Disability Services
Unemployment
Supplemental Security Income (SSI)
CHIP
TANF
WIC
Utility Assistance
Other
Please explain:
What do you consider to be barriers to receiving services for you, your family , or other families in the community?
Not aware of existing services
Lack of Transportation
Eligibility and policies exclude certain demographics
Staff are rude or nonsensitive to needs
Inconvenient Agency/ Organization hours
No access to technology (phone ,computer ,etc.)
Other
Other Comments or Concerns:
What would be the best way to communicate what is happening in the community?
Word of mouth
Posters/Flyers
Cable TV
Radio
Newspaper
Phone
If services were offered in a neighboring city or community, would you be willing to go there?
Yes
No
Yes, but in need of transportation
Yes, but in need of child care
Other
Please explain:
Please indicate your interest in seeing the following services or information offered at your Family Resource Network or a nearby agency/org:
Outreach
Stress Reduction Classes
Individual Counseling
Basic Skills Training
WIC, TANF services
Job Training/ Placement
Substance Use Disorder services/ Treatment
Anger Managment
Family Therapy
Adult Edu./ GED Preparation
Support Groups
Child Safety Classes
Health Screening/ Assistance
Food Stamps
Child Development /Parenting classes
Computer Training
Daycare/ Pre-school, Headstart
Foster Care
Housing Assistance
Budgeting/ Finance Counseling
Emergency Housing/ Homeless Shelters
Unemployment Compensation
Child Abuse/ Neglect Education
Veteran Services
Legal Assisatnce/ Aid
LGBTQ+ Services
Other
Other information or services needed:
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4. Volunteering
Would you be interested in volunteering with different agencies in the community as the need arises?
Yes
No
Depends
I already volunteer
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: