SAMPLE COMMUNITY NEEDS ASSESSMENT SURVEY FOR THE ROSS SERVICE COORDINATOR PROGRAM

Part I Household Information
1. Are you an adult 18 years or older? (check one)
2. Are you the head of household? (check one)
3. Does anyone in your household have a mental or physical disability? (check one)

Part II: Community/Household Needs:


4. How would you rate the following issues for your household?
Availability of Job Training Opportunities (check which applies)
Availability of Jobs for Youth (check which applies)
Availability of Jobs for Adults (check which applies)
Education (check which applies)
Availability of affordable, reliable child-care services (check which applies)
Lack of computer/digital literacy (check which applies)
Lack of affordable Internet service (check which applies)
Cost of living (check which applies)
Income/wages (check which applies)
Debt (check which applies)
Financial Security (check which applies)
Availability of financial services (check which applies)
Availability of financial counseling (check which applies)
Elderly living assistance (62+) (check which applies)
Physical health (check which applies)
Mental health (check which applies)
Seeking employment with a criminal record (check which applies)
Obtaining a degree/diploma with a criminal record (check which applies)
Availability of substance use services (check which applies)
Availability of substance use services (check which applies)
Need for substance use treatment (check which applies)

5. What are the things that make it difficult for you or other adults in your household to find and/or keep work?


BARRIERS
Check All That Apply

6. Do you or others in your household have interest in the following?


INTERESTS
Check All That Apply

7. Do you or another adult in your household have difficulty with any of the following?


SUBJECT/SKILL
Check All That Apply

8. What are the primary health care needs of your household?


HEALTHCARE NEEDS

Check All That Apply

9. What is your gender?
GENDER - Check one

10. What is your age?
AGE RANGE - Check one

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