Council of the Southern Mountains

 

COUNCIL OF THE SOUTHERN MOUNTAINS
P.O. BOX 85
NORTHFORK, WV 24868
TELEPHONE: 862-3144
2008 COMMUNITY NEEDS ASSESSMENT SURVEY

Name: (Optional):_______________________________Date:_____________________

1. Where do you live?

2. Total number of household members. Please count yourself.
a. ages 0-2
b. ages 3-4
c. ages 5-12
d. ages 13-18
e. ages 19-49
f. ages 50-65
g. ages 66+

3. Total males in household:
Total females in household:

4. Your race/ethnicity:
a. Black/African American
b. Hispanic/Latino
c. White
d. Other

5. Sources of household income:
a. full-time employment (30+hours/week)
b. part-time employment (less than 30 hrs/wk)
c. child support
d. social security
e. pension
f. SSI
g. Unemployment
h. Temporary Assistance to Needy Families (TANF)
i. Other

6. What is the highest level of education?
a. grades 8 and under
b. grades 9-12 (did not graduate)
c. high school graduate
d. some college
e. 2 year college degree
f. 4 year college degree
g. Post graduate degree

7. Your marital status:
a. single
b. married
c. separated
d. divorced
e. widow/widower

8. If you have separated or divorced, which of the following, if any, has been
affected:
a. lost home
b. poor credit/bankruptcy
c. more dependent on social services
d. had to raise children alone
e. had to go back to work
f. I lost family/friends

9. Please rate your 5 greatest needs not being met by placing a 1 for the greatest up 5 being the least of the group:
a. affordable housing/safer place to live/own a home (circle one) ________
b. a job ________
c. better job ________
d. a car ________
e. better public transportation ________
f. better health care ________
g. health insurance/dental insurance ________
h. more money to help support family/less debt ________
i. more support from family/friends ________
j. affordable child care ________
k. a chance to go back to school ________

11. Please list the 5 greatest needs for McDowell County:
a. improved educational system
b. better child care
c. more post secondary college classes
d. jobs-economic development
e. jobs paying a living wage
f. better recreational facilities-a fitness center
g. more after school/summer recreation programs for children
h. summer feeding program for youth
i. better roads
j. better-affordable-decent housing
k improved infrastructure-water and sewage disposal
l. community programs to decrease teen pregnancies
m. community programs to decrease high school drop-out rate
n. improved cell phone reception-more towers
o. tourism initiatives

12. Housing status:
a. own home
b. rent
c. section 8 rental
d. live in public housing
e. live with family or friends
f. community shelter
g. homeless

13. Are you in need of housing rehabilitation/weatherization for your home?
a. Yes
b. No

14. Do you receive food stamps?
a. Yes
b. No

15. In the past 12 months have you or your family used a Food Pantry?
a. Yes
b. No
If yes, how often?
a. every month (12 times a year or more)
b. most months (6-9 times a year)
c. once in a while (2-3 times per year)

16. Do you have enough food to provide 3 meals a day?
a. Yes
b. No

17. Do you have health insurance coverage?
a. personal paid coverage
b. employer provided insurance
c. Medicare
d. Medicaid
If yes to one of the above, for whom?
a. for self only
b. for children only
c. for self and children

18. Are you able to obtain health/medical care when you need it?
a. Yes
b. No
19. Have your children gone to the doctor in the past year?
a. Yes
b. No

20. Have your children gone to a dentist in the past year?
a. Yes
b. No

21. Have you ever wanted to go to the doctor/dentist but didn’t because you didn’t have the money?
a. Yes
b. No

22. Do you have trouble finding a doctor/dentist because they don’t accept your
insurance?
a. Yes
b. No

23. Does anyone in the household have a problem with drugs/alcohol or a mental
health disability that has resulted in loss of job or relationship problems?
a. Yes
b. No

24. Which of the following do you have?
a. Checking account
b. Savings account
c. Pension/retirement account
d. Credit cards

25. Have you filed for bankruptcy in the past five years?
a. Yes
b. No

26. Do you have a job?
a. Yes
b. No

27. How do you have your taxes prepared?
a. I do them on a paper return
b. I do them on line
c. a friend/relative does them
d. I pay a tax preparer to do them for me
e. I go to a free tax service
f. I don’t file tax returns


28. Do you use childcare?
a. Yes
b. No

29. Is your childcare reliable?
a. Yes
b. No

30. What do you do most often when children are sick?
a. family member provides care
b. friend provides care
c. I stay home
d. Send them to daycare sick

31. How much do you pay for childcare?
a. Weekly:__________________
b. Monthly:_________________

32. What is the most important thing you considered when choosing this
childcare?
a. I could afford it
b. Location
c. Recommendations of family/friends
d. Recommendations of agency
e. n/a

33. Did you receive help to pay for any of the following this year?
a. Oil, propane, gas or electric for your heating/cooling
b. A utility bill that is not your heat source (water, sewage, telephone, etc.)

34. During the past two years, did any of the following happen to you?
a. evicted from home or apartment
b. moved in with family/friends
c. moved into shelter or homeless
d. none of the above

35. How much do you pay each month for rent or mortgage?
________________________

36. Most frequent method of travel?
a. own car
b. take a bus
c. get rides from family/friends
d. taxi
e. walk or ride bikes

37. Do you own a vehicle?
a. Yes
b. No

Is it in working condition?
a. Yes
b. No

38. Is transportation ever a problem for you to do any of the following?
a. grocery shopping
b. doctor/dentist
c. educational event/school
d. work
e. church

39. Have you called the toll-free information hotline 2-1-1 in the last year?
a. Yes
b. No
If yes, how many times:
a. 1 time
b. 2-5 times
c. 6 or more times

40. Are you registered to vote?
a. Yes
b. No

41. Do you have access to a computer at home or work?
a. Yes
b. No

42. Do you use the internet?
a. Yes
b. No
If yes, where do you most use the internet?
a. home
b. work
c. library
d. community agency
43. For what purposes do you use the internet (check all that apply)?
a. information/news
b. education/on line courses
c. shopping
d. entertainment


44. Were you involved in any of the following community activities this year?
a. I voted
b. I volunteered at a community organization
c. I was active at church
d. I was active at my child’s school
e. I was active in my community/neighborhood

45. Please list the services provided by the Council of the Southern Mountains
that you have accessed in the past or need to access now:
a. Food Pantry
b. Utility Assistance
c. Weatherization Assistance Program
d. Foster Grandparent Program-Either as a Volunteer or Volunteer Station
e. Retired and Senior Volunteer Program as a Volunteer in Neighborhood Watch Groups, Call Reassurance Program to Shut-Ins, Disaster Shelters/Preparedness.
f. Mentoring Children of Prisoners
g. Aged and Disabled Waiver Program
h. Title XIX Waiver Program
i. Other-Referral Services to other providers

46. (Optional) If you would like to have assistance or learn more about the services of the Council of the Southern Mountains, please enter your name, address and telephone number:

Name:
Address:


Telephone:







Thank you for completing our survey. Your responses will help us try to meet the needs of people in McDowell County. This information is confidential and individual names or responses will not be published.