20%

Personal information
Applicant First Name *
Applicant Middle Name
Applicant Last Name *
Social Security Number * ( 9 digit )
Date of birth: *
Location *
Have you been affected by COVID-19 *
Yes
No

The following questionnaire will only take a few minutes to compete and it will assist in helping people, meeting the community needs and providing hope. All information will be kept confidential and your name is not required on the questionnaire. THANK YOU FOR YOUR TIME!

EVERY QUESTION IS TO BE COMPLETED OR THIS QUESTIONNAIRE WILL BE REMOVED FROM THE RESULTING POOL. Please check the appropriate answer for each question.
Basis demographic information.
What is your role in the community? (Please select the best choice which fits your role when completing this survey.)
What is your age?
What is your education level?

As part of the local community action agency ongoing community needs assessment, we are asking you assist us by completing the following server. The results of the survey assist in targeting funding toward the greatest community needs.

The following topic areas require that you mark the three most important needs in each category. Please take the time to review each carefully before making your decision. As always, we value your input and feedback.

EDUCATION-Mark the three most important needs.
Employment - mark the three most important needs.
Health –mark the three most important needs
Housing- mark the three most important needs
INCOME AND ASSET BULINDG –Mark the three most important needs.
Support services - Mark the three most important needs.
OVERALL NEED – mark the three most important needs.
Back
40%

Contact Information
Physical Address*
Address line 1 *
Address line 2
City *
State *
Zip Code * ( 5 digit )
Mailing Address (if different from Physical Address)
Address line 1
Address line 2
City
State
Zip Code ( 5 digit )
Driver License or ID No
Expiration
Home phone
Cell
Email
60%

Demographics
Gender *
Do you need home repair services?
Yes
No
What year was your home built?
Do you own your home?
Yes
No
Disabling Condition *
Marital Status *
Household Type *
Housing Type *
Military Status *
Race *
Ethnicity *
What do you need assistance with? *
80%

Other Household Members if any – complete for each member

Members - One
First Name
Middle Name
Last Name
Gender:
Date of birth
Disabling Condition :
Marital Status:
Members - Two
First Name
Middle Name
Last Name
Gender:
Date of birth:
Disabling Condition :
Marital Status:
Members - Three
First Name
Middle Name
Last Name
Gender:
Date of birth:
Disabling Condition :
Marital Status:
Members - Four
First Name
Middle Name
Last Name
Gender:
Date of birth:
Disabling Condition :
Marital Status:
Members - Five
First Name
Middle Name
Last Name
Gender:
Date of birth:
Disabling Condition :
Marital Status:
Members - Six
First Name
Middle Name
Last Name
Gender:
Date of birth:
Disabling Condition :
Marital Status:
Members - Seven
First Name
Middle Name
Last Name
Gender:
Date of birth:
Disabling Condition :
Marital Status:
Members - Eight
First Name
Middle Name
Last Name
Gender:
Date of birth:
Disabling Condition :
Marital Status: