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
65 and over
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?
Total Annual Household Income:
$15,000 or less
$90,001 or more
What is your education level?
Less than high school
High School Diploma/GED
2-4 Year College Degree
Some Graduate Level
Are you registered to vote?
What is your health status?
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
Smoke 1 or less pack daily
Smoke 2 or more pack daily
Smoke pipe/ cigar regularly
Use smokeless tobacco
Do you have health insurance (check all that apply)?
Receive through employment
CHIP (Children's Health Insurance Program)
Children covered but adults are not
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)
After School Programs
Senior Citizen Care
Food and Clothing
Illegal Drugs/ Alcohol
Adult Education/ GED
Nutrition Access/ Info
Comments on those needs or concerns:
What type(s) of services do you or your family receive?
Do not receive public assistance
Free/ Reduced School Lunch
HUD (Housing Assistance)
Child Care Assistance
Vouchers of any kind
Supplemental Security Income (SSI)
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 Comments or Concerns:
What would be the best way to communicate what is happening in the community?
Word of mouth
If services were offered in a neighboring city or community, would you be willing to go there?
Yes, but in need of transportation
Yes, but in need of child care
Please indicate your interest in seeing the following services or information offered at your Family Resource Network or a nearby agency/org:
Stress Reduction Classes
Basic Skills Training
WIC, TANF services
Job Training/ Placement
Substance Use Disorder services/ Treatment
Adult Edu./ GED Preparation
Child Safety Classes
Health Screening/ Assistance
Child Development /Parenting classes
Daycare/ Pre-school, Headstart
Budgeting/ Finance Counseling
Emergency Housing/ Homeless Shelters
Child Abuse/ Neglect Education
Legal Assisatnce/ Aid
Other information or services needed:
Would you be interested in volunteering with different agencies in the community as the need arises?
I already volunteer
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