Community Needs Assessment – Participant Survey – Alabama Council on Human Relations, Inc

How are you currently affiliated with ACHR? *

Name *

First

Last

Demographics information

Please complete the next few questions about where you currently live, race, age, gender, and estimated income.

Your County: *

Your City/Community: *

If other, please list:

Your Zip Code: *

Gender: *

Marital Status: *

Total number of people living in your household: *

Ages of each person living in your household: *

Ages

Numbers

Numbers *

Your monthly household income: *

Race: *

If other, please specify:

Hispanic/Latino: *

Community Programs

Please complete the next few questions regarding ACHR and community programs that you have used.

Which of the following ACHR programs have you used (currently or in the past- check all that apply)? *

If not satisfied, please specify:

Were you satisfied with the programs you checked? *

If not satisfied, please specify:

Which of the following other programs have you used? (Check all that apply) *

Were you satisfied with the programs you checked? *

If other, please specify:

Current situation in your community

What do you think of the current state of the following in your community? Please check the appropriate dropdown box for each.

1. Employment/good paying jobs *

2. Job Training *

3.Adult Education (GED, technical courses, ect.) *

4. Transportation (to work, childcare, grocery store, ect.) *

5. Financial/budget training and information *

6. Comsumer skills training and information *

7. Parenting skills training and information *

8. Wraparound child care (before/after school and during summer) *

9. Daycare (full-time/all day) *

10. Housing (safe and comfortable) *

11. Housing counseling *

12. Healthcare *

13. Health insurance for children *

14. Health insurance for adult *

Concerns in your community

How big a problem are the following in your community? Please check the appropriate dropdown box for each.

15. Confusing consumer practices (payday loans, rent-to-own, etc.) *

16. Crime *

17. Gang Activity *

18. Violence *

Please specify the types of violence. (check all that apply)

A. Community
B. Schools
C. Domestic - in homes

19. Abuse *

Please specify the types of abuse. (check all that apply)

A. Physical
B. Emotional
C. Sexual

20. Drugs (street or misused prescription) and/or alcohol *

21. Discrimination *

If problem, please specify:

If other problems exist, please describe:

22. Other Problems *

What are the most serious issues/or problems in your community?

What services are hardest to find or to access in your community?

Please complete the questions in the next few sections about your household.

Job Status

Please answer the following questions concerning your job status.

1. Are you: *

2. Is there another adult in the household?

3. If there is another adult, is s/he: *

4. Do you or anyone in your household receive any type of job-related assistance? *

If yes, please specify the type of assistance

5. Is a criminal record making it difficult for you or anyone in your household to get a job? *

Housing

Please answer the following questions.

6. Is your current housing affordable? *

Approximate monthly payment: $

7. Do you live in: *

Public housing
Apartment
House
Mobile Home

8. Do you: *

Own
Rent
Live in residence owned or rented by someone else

9. Are you satisfied with your current housing? *

10. Has discrimination ever been a problem for you when trying to rent or buy housing? *

If yes, please describe:

11. Are your utility bills too high because your home is in need of weatherization services (e.g., insulation, roof repairs, ect.)? *

Education

Please answer the following questions concerning your education status.

12. How far did you go in school? *

13. Can you read, write, and do math well enough to do tasks such as fill out a job application or a medical form or help young children with homework? *

14. Do you or anyone in your household receive any type of education-related assistance? *

If yes, type of assistance:

Health

Please answer the following questions concerning your health care.

15. What health insurance do you have? *

16. What health insurance do your children have? *

17a. Is a medical problem currently causing a problem for you or anyone in your household? *

If yes, please describe problem?

17b. Is a dental problem currently causing a problem for you or anyone in your household? *

If yes, please describe problem?

17c. Is a mental health problem currently causing a problem for you or anyone in your household? *

If yes, please describe problem?

18. When adults in your household need medical care, where do they most often go? *

Family doctor
Any doctor available (such as Urgent Care)
Hospital emergency room
Don’t go anywhere

19. When children in your household need medical care, where do they most often go? *

Family doctor/ Pediatrician
Any doctor available (such as Urgent Care)
Hospital emergency room
Don’t go anywhere
not applicable (no child in the household)

20. Do children and adults in your household get needed dental care, including exam/cleaning? (check all that apply) *

Adults do
Children do
Adults do not
Children do not

21. Do you or anyone in your household receive any type of pregnant teen/teen mother-related assistance? *

If yes, please specify type of assistance:

22. Do you or does anyone in your household have a disability? *

If yes, how many have a disability?

Give age and disability of each:

23. Do you or anyone in your household need help with an addiction to opioids or other drugs or alcohol? *

If yes, please specify substance(s)

Food

Please answer the following questions about food in your home.

24. Do you and the other members of your household have enough to eat? *

Always
Usually
Not usually
Never

25. Do you and the other members of your household eat healthy meals and snacks? *

Always
Usually
Not usually
Never

25a. Are you or anyone in your household more than 30 pounds overweight? *

If yes, how many adults?

If yes, how many children?

26. Are you or anyone in your household interested in learning more about community gardening? *

27. Do you or anyone in your household receive any type of food/nutrition-related assistance? *

If yes, what type of assistance?

28a. Do you/anyone in household need help planning healthy meals ? *

28b. Do you/anyone in household need help planning an easy exercise program? *

Household management

Please answer the following questions about your household.

29. Do you or anyone in your household have a savings or checking account? *

30. Do you or anyone in your household have a credit or debit card? *

31. Are household bills paid on time? *

Always
Usually
Not usually
Never

32. Are basic household needs being met? *

If no, please explain why not:

If yes - with help, please explain the kind of help:

33. Are you satisfied with the way that money is managed in your household? *

If no, please explain why:

34. Is there a computer in your household? *

If yes, do you have internet access?

35. Do you have Internet access via a Smart Phone, iPad or other device? *

If yes or sometimes, what type of device:

36. Do you or anyone in your household own or have easy access to a car or truck or motorcycle? *

37. Do you or anyone in your household ever have to pay someone for a ride somewhere? *

If yes or sometimes, about how much usually:

38. Do you or anyone in your household use public transportation (Lee-Russell Public Transit)? *

39. Do you ever use taxicabs for transportation? *

Emergency/Crisis Situations

Please answer the following questions about potential emergencies or crises in your household.

40. Are you or anyone in your household currently dealing with an emergency or crisis situation? *

If yes, please explain what kind:

41a. About how often do you or someone in your household need help with housing? *

41b. About how often do you or someone in your household need help with food or clothing? *

41c. About how often do you or someone in your household need help with utility bills? *

41d. About how often do you or someone in your household need help with child care? *

42. Are you or anyone in your household involved in a program to help prevent emergency and crisis situations? *

If yes, please tell what program(s):

Community Involvement

Please answer the following questions about your household's activity in the community.

43. Do you or any other adult in your household participate in community activities such as church, Head Start (e.g., policy council, fatherhood program, etc.), clubs, politics, etc.? *

If yes, please explain what activities:

44. Where do you get information about community events and services? (Check all that apply) *

If other, please explain what activities:

45. What are the biggest barriers to you having the quality of life you want for you and your family?

46. What do you and your family need to overcome these barriers?

Other Needs/Wants

47. Check all of the following that you or any adult in your household need and/or want more information about: *

If you would like any information about these programs, please contact your Family Engagement Advocate at 334-821-8336.

If other, please explain:

48a. Do you have children ages 6 -18? *

48b. Do you have children ages 3 -5? *

48c. Do you have children ages 0 -3 or are you or a member of your household pregnant? *

49. If yes, do you have a safe place for them to be when you are working? *

If yes, please explain:

50. Do you have concerns in your household with a child or adult acting out? *

51. How many children five years of age and younger live in your household?

One
Two
Three
More than three

If more than three, how many:

52. Do you work outside the home?

53. If you work outside the home, where do your children five years of age and younger stay while you’re gone? (Check all that apply)

If other, where:

53b. If you do not work out of the home and you have children ages 0-3 years old, are you interested in the Early Head Start /home based program?

54. Would you get a job or work more hours outside the home if additional, more affordable hours of child care were available?

55. If you have a child in Head Start or Early Head Start, are additional, more affordable hours of child care needed for that child (or children)?

56. Do you or anyone in your household have a child four years of age or younger who needs special care for a disability or serious illness?

If yes, what disability or serious illness does your child have:

If yes, what special care is needed: