Needs Assessment Survey

Please help us assess the needs of Anne Arundel County. With your help we can provide services that will benefit you and our community. Completion of the survey is very important. All information will remain confidential. Thank you for your participation and honesty.

Please check or fill in the block for the appropriate response for each of the following:

Assessment

A. What is you or your family’s most urgent need?

1 Employment

2 Transportation

3 Child Care

4 Education

5 Food/nutrition

6 Housing

7 Health Care

8 Drug / alcohol treatment

9 Other______________________

B. Did you know that the Anne Arundel Community Action Agency has a web site (http://www.aaceoc.org)?

1 Yes 2 No

C. Have you ever used the Anne Arundel Community Action Agency?

1 Yes (go to question D) 2 No (go to question I)

D. Did we provide a service or refer you to another agency?

1 AAEOC provided a service 2 You were referred to another agency.

 

E. What service did we provide?

1 Head Start

2 Early Head Start

3 Case management

4 Housing

5 Energy assistance

6 Annapolis Youth Services Bureau

7 Senior employment and nutrition

F. How would you rate our service?

1 Excellent 2 Good 3 Fair 4 Education

G. How many children in your household go to Head Start?

1 0 2 1 3 2 4 3 or more

H. How many children in your household go to Early Head Start?

1 0 2 1 3 2 4 3 or more

I. Do you know about the Maryland Children’s Health Program (MCHP) that gives free health services for children and pregnant women in Anne Arundel County who have low to average incomes?

1 Yes 2 No

J. What do you think are the major causes of poverty where you live? Check all that apply.

1 Divorce

2 Lack of training / education

3 Not enough jobs

4 Other (specify:______________________________)

 

K. What services or programs do you think your community needs? Check all that apply.

1 Adult day care

2 Job training

3 Spouse abuse shelter / counseling

4 Day care / child care

5 Youth education

6 Health / nutritional counseling

7 Budgeting workshops

8 Volunteer programs

9 Education improvement

10 Other______________________

L. What makes it tough for you and your family to get a job, or get a better job?

1 No child care

2 Health problems

3 Discrimination

4 No training / lack of skills

5 Lack of transportation

6 Other______________________

M. Where do you get most of your information?

1 Newspaper (specify:_______________________)

 

2 TV (specify:_______________________)

 

3 Radio (specify:_______________________)

 

Profile

N. What county do you live in?

1 Anne Arundel 2 Other (specify:_____________________)

 

O. What zip code do you live in?

1 Zip Code (specify:_____________________)

P. What is your gender?

1 Male 2 Female

Q. How many people are in your household?

1 1

2 2

3 3

4 4

5 5

6 6

7 Other______________________

R. How many children are in your household below the age of 18?

1 0

2 1

3 2

4 3

5 4

6 5

7 6 or more

S. How many senior citizens are in your household over age 64?

1 0

2 1

3 2

4 3

5 4 or more

 

T. What is your age?

1 18 - 29

2 30 - 44

3 45 - 59

4 60 or more

U. What is your race or ethnic background?

1 Black / African-American

2 Caucasian

3 Asian

4 Hispanic

4 Other __________________________

 

V. What is the highest level of your formal education?

1 Less than high school diploma

2 GED

3 High school diploma

4 Some college

5 Associates degree

6 Bachelors degree

7 Post-graduate work

W. What is your marital status?

1 Single

2 Married

3 Separated

4 Divorced

5 Widowed

6 Other _______________________

 

X. Do you own your home or is it rented?

1 Own 2 Rent

Y. What is your household income?

1 $0 - $7,000

2 $7,001 - $14,000

3 $14,001 - $21,000

4 $21,001 - $28,000

5 $28,001 - $35,000

6 Over $35,000

Z. What is your religion?

1 Protestant

2 Catholic

3 Agnostic / Atheist

4 Jewish

5 Other _______________________________

Comments

AA. In your own words, describe the problems that you are struggling with right now:

1.