Community Needs Assessment Template
Community Name
Community Location
Personal Data
Name
First Name
Last Name
Age
Phone Number
-
Area Code
Phone Number
Email Address
example@example.com
Job/Field of expertise
Educational Level
Professional Degree
Bachelor's Degree
Associate Degree
College Degree
Highschool Graduate
Highschool No Diploma
Employment Details
Employment Status
Working
Self-employed
Retired
Unemployed
What are the possible reasons why you are unemployed? (Health issues, mental problems, criminal background, etc.)
Would you like to be contacted if there are job events?
Yes
No
List of Agencies who are helping your family (like Name of Church, Charities, Officials).
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Household Information
Residence status
Own
Rent
Living with family
Living with friends
Homeless
Civil Status
Single
Maried
Widowed
Divorced
Do you have child?
Yes
No
Who is taking care of your child/children?
Do you need different help in taking care of your child? If yes, then what kind of you help do you need?
Do you have an adult or senior in your family that needs care?
Yes
No
How many are you in the house?
Household monthly income gross ($)
Household yearly income gross ($)
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Financial Data
What monthly bills are you currently paying?
Electricity
Water
House Rent
Card loan
Insurance
Phone
Internet
Where do you get your income or money for daily needs?
Employment income
Pension
Social Security Service
Loans
No income
Do you have an insurance (health, life, etc.)?
Who provides your insurance?
Own
Employer
Government
Are you currently experiencing financial problems? If yes, then please specify below:
Others
Do you need help in regards to your daily transportation? If yes, then please specify below and provide the reason why.
Are you having issues related to housing? Is the housing not affordable? If yes, let us know the reason why.
Comments/Suggestions/Feedback:
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