2007-2008 Gateway CAA Needs Assessment Survey (Agency Customers)

Instructions

Gateway Community Action Needs Assessment Survey 2007-2008 Agency Customers The following questionnaire will only take a few minutes to complete and it will assist Gateway Community Action in identifying priorities for the types of programs we provide to the communities we serve. All of the information will be kept confidential and your name is not required on the questionnaire. THANK YOU FOR YOUR TIME! Please check the appropriate responses.

Check section

Please check the appropriate responses.

1.	In which county do you live?

Gender?

3.	How old are you?

Are you?

	Married
	Divorced
	Separated
	Single
	Widowed
	Other:

6.	Does your house have the following (check all that apply):

	(Select all that apply.)
	Septic Tank
	Sewer Connection
	Other:

7.	What type of fuel do you use for heating your house?

	(Select all that apply.)
	Natural Gas
	Electricity
	Solar Energy
	Propane
	Kerosene
	Fuel Oil
	Coal
	Wood
	Other Fuel:

8.	How many live in your home?

9.	Do you or any of your children have a disability?

10.	Are you raising children other than your own?

	(Select all that apply.)
	No
	Yes, Grandchild
	Yes, Foster Child
	Yes, Other:

11.	What do you use as transportation?

12.	Is anyone in your household receiving any of the following?

	(Select all that apply.)
	Food stamps
	SSI (Supplemental Security Income)
	Medicaid
	Vocational Rehabilitation
	Rent Subsidy (Housing Authority, GRFA, etc.)
	TANF (Temporary Assistance for Needy Families)
	Social Security
	Medicare
	Unemployment Benefits
	None

13.	What is your primary source of income?

	(Select all that apply.)
	Wages from work
	Retirement/Pension
	Child Support
	K-TAP
	Social Security
	SSI
	Worker's Compensation
	Family/Friends give you money
	Other:

14.	Are any of the items listed below a goal for you or anyone in your household within the next year?

	(Select all that apply.)
	To make enough money so that we are not on any government assistance
	To own our own house
	To have a more reliable means of transportation
	To get more education or job training
	To pay our bills on time
	To get additional medical treatment
	Other:

Ranking Section

**Please rank the following by order of importance to you. Circle the number that represents the degree of importance each listed items is to YOU. Your range begins at 1 for Most Important and ends at 9 for the Least Important. Circle only 1 number from 1 to 9 for each item listed. 1 = Most Important to Least Important = 9

15.	Employment (job skills, job retention, benefits, higher wages)

16.	Education (GED, post-secondary programs, adult education classes)

17.	Income Management (budgeting, food stamps, child support, legal services)

18.	Housing (Weatherization, home ownership, housing repair, rental assistance)

19.	Emergency Assistance (food/clothing banks, spouse abuse/homeless shelter, heating assistance)

20.	Nutrition (nutrition education, garden seeds/supplies, hot meals)

21.	Linkages (outreach, volunteers, community meetings/projects)

22.	Self-Sufficiency (child care assistance, parenting classes)

23.	Health (medical assistance, vaccinations, medications, vision/dental assistance)

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