Sample Community Needs Assessment_NOFO2025.pdf

SAMPLE COMMUNITY NEEDS ASSESSMENT SURVEY

FOR THE ROSS SERVICE COORDINATOR PROGRAM

Part I: Household Information:

1. Are you an adult 18 years or older? (circle one)

Yes No

2. Are you the head of household? (circle one)

3. Does anyone in your household have a mental or physical disability? (circle one)

Part II: Community/Household Needs:

4. How would you rate the following issues for your household?

Issue Serious Problem

Moderate Problem

Not a Problem Does Not Apply to My Household

Availability of job training opportunities

Availability of jobs for adults

Availability of jobs for youth

Education Availability of child-care services

Lack of computer/digital literacy

Cost of living Income/wages Debt Financial security Availability of financial services

Availability of financial counseling

Elderly living assistance (62+)

Physical health Mental health

Seeking employment with a criminal record

Obtaining a degree/diploma with a criminal record

Availability of substance abuse services

Need for substance abuse treatment

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

BARRIER

Check All that Apply

Nothing Need affordable childcare Caring for a family member who is sick or disabled

Do not speak English well Need computer training Need transportation Need job experience Need job training No job opportunities Do not have a high school diploma/GED Do not have a college degree Disability Criminal record Lack of transportation Other – specify Other – specify Other – specify Don’t know No response

6. Do you or others in your household have interest in the following? (check all that apply)

INTEREST Check All that Apply

GED/Adult education Vocational training Increasing income Getting a job Getting a better job Computer training Saving money Eliminating debt 2-year college

7. Do you or another adult in your household have difficulty with any of the following? (check all that apply)

SUBJECT/SKILL Check All that Apply

Reading Math Writing Speaking English Writing English Using a computer Other – specify Other – specify Other – specify Don’t know None

8. What are the primary health care needs of your household? (check all that apply)

HEALTHCARE NEEDS Check All that Apply

Primary health care Pediatric (child) care Prenatal (pregnancy) care Dental care Healthcare education/prevention Nutrition and exercise programs Services to help alleviate stress/anxiety/depression

Assistance with daily living for elderly/disabled residents

Health screening services Substance abuse treatment Smoking cessation programs Drinking cessation programs Transportation to healthcare services Other – specify Other – specify Other – specify Don’t know None

4-year college Trade school Other (specify) Other - specify Don’t know None

9. How would you rate the following services available in your community?

Services Check All that Apply

10. What is your gender? (check one)

GENDER Check One

Female Male

11. What is your age (check range)

AGE RANGE Check One

18-24 25-34 35-44 45-54 55-65 65 or older

12. Which of the following community assets do you currently use, and which do you think are most needed in your community? (Check all that apply and indicate if they are needed)

COMMUNITY ASSET CURRENTLY USE NEEDED IN COMMUNITY

Parks and Recreational Spaces

Public Libraries Community Centers Local Businesses and Markets Civic Organizations

Religious or Spiritual Institutions

Health and Wellness Services Educational Programs and Resources

Public Transportation Social Services and Support Organizations

Job Training and Employment Services

Senior Services and Supports Food Assistance Programs (food banks, community gardens, etc.)

Technology Access (public Wi-Fi, computer labs)

Reentry Services