COMMUNITY NEEDS SURVEY
Crockett County Community Family & Resource Center Empowering Communities For Lifelong Success and Enduring Positive Impact
What are some things you would like to see in your neighborhood that you do not see(choose all that are true)
*
What are some things you see in your neighborhood but would not like to see (choose all that is true
*
Do your local community resources meet your needs?
*
Please Select
Yes
No
Do you know where to find resources when you need them?
*
Please Select
Yes
No
Sometimes
Are you worried about losing your home within the next 2 months?
*
Please Select
Yes
No
Do you have any problems with your home, like bugs, mold, leaks, or HVAC?
*
Please Select
Yes
No
How often do you worry about paying for things like food, electricity, and rent?
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Never
Sometimes (1-4 times a year)
Often (monthly)
Always
Do you think there are enough jobs where you live?
*
Please Select
Yes
No
Where do you mostly look for job opportunities?
*
Temp Agencies
Newspapers & Magazines
From other people
Social Media
Online Job Websites
Are you happy with the schools and learning options in your community?
*
Please Select
Yes
No
Don’t know school options
What things affect your choices about education for yourself (choose all that apply)
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Attendance Options (virtual, in-person, hybrid remote)
Quality of the programs at the education institute
Cost
Influence of family and friends
Reputation of school and staff
Transportation Options
Other
In the last year, did you or someone in your family need to visit a doctor but couldn’t?
*
Please Select
Yes
No
When someone is sick or hurt, and it is non-life threatening, what do you usually do first?
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Call 911/go to the emergency room
Left over prescription
Go to Urgent Care (such as minor med)
Go to Veterans Hospital
Home Remedies (over the counter)
Call your primary doctor (that you see regularly)
Natural/Herbal Remedies
Other
Do you feel supported by your family and friends?
*
Please Select
Yes
No
Sometimes
No family and friends
Do you feel safe where you live?
*
Please Select
Yes
No
Sometimes
Do you currently have any of these needs (please select any unmet needs that you may have)
Stable Housing
Transportation Issues
Food
Medical Care
Taking care of children
Job
Therapy/Counseling
Sense of Connection
Mentorship
Other, please specify ______________________
Would you like to help make your community better?
*
Please Select
Yes
No
Follow-Up
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Demographics and Contact Information
Name
*
First Name
Last Name
How old are you?
*
What is your gender?
*
Male
Female
Transgender
Nonbinary
Prefer not to answer
What is your race or ethnicity? You can choose more than one
*
White
Black or African American
Hispanic
Latino
Arab
Native American or American Indian
Asian
Pacific Island
What is your zip code?
*
What is your address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your email address?
*
example@example.com
Submit
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