Community Diagnosis Questionnaire
Thank you for participating in this community diagnosis survey. Your feedback will help us understand the needs and challenges of our community better.
Demographic Information
Full Name
First Name
Last Name
Age
Gender
Male
Female
Non-binary
Prefer not to say
Occupation
How long have you lived in this community?
Community Assessment
How would you rate the overall quality of life in our community?
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
What are the main strengths of our community?
What are the main challenges or issues facing our community?
What services or resources do you feel are lacking in our community?
How often do you participate in community events or activities?
Never
Rarely
Sometimes
Often
Always
How would you rate the accessibility of community services (e.g., healthcare, education, transportation)?
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
What improvements would you suggest for our community?
Final Thoughts
Any additional comments or suggestions?
Would you like to be contacted for follow-up discussions?
Yes
No
If yes, please provide your contact information (email or phone number):
Submit
Should be Empty: