Community Needs Survey

This survey is voluntary and confidential. Your participation and response will not affect the services you receive from CAP-HC. Please answer the following 45 questions and provide us with your name, telephone number, and zipcode of residence in the box below if you would like to be entered into a drawing for a chance to win one of four $25 gift cards. Winners will be notified by the first week of October 2017. Thank you.

1. How much of a problem is access to health care for your household?

Not a problem
A small problem
A big problem

2. How much of a problem is access to a dentist for your household?

Not a problem
A small problem
A big problem

3. How much of a problem is access to mental health care for your household?

Not a problem
A small problem
A big problem

4. How much of a problem is having enough money to meet basic needs for your household?

Not a problem
A small problem
A big problem

5. How much of a problem is access to safe and affordable housing for your household?

Not a problem
A small problem
A big problem

6. How much of a problem is paying for child care for your household?

Not a problem
A small problem
A big problem

7. How much of a problem is finding child care that is open during the times you need it for your household?

Not a problem
A small problem
A big problem

8. How much of a problem is access to transportation for your household?

Not a problem
A small problem
A big problem

9. How much of a problem is access to affordable car insurance for your household?

Not a problem
A small problem
A big problem

10. How much of a problem is access to healthy food for your household?

Not a problem
A small problem
A big problem

11. How much of a problems is access to higher education for your household?

Not a problem
A small problem
A big problem

12. What is one thing that would help the most to meet the needs of those living in your household? (including yourself, children, other family, or friends)

13. How many adults age 18 or older, including you, live in your household?

14. How many children under age 18 live in your household?

15. What is your age (in years)?

16. What is your gender?

Female
Male
Other

17. What is your race/ethnicity?

18. What language is mostly spoken in your home?

19. What is the highest level of education you have completed?

20. What is your current employment status?

21. Does your employer offer you health insurance?

22. Does your employer offer you paid time off?

23. Do the people in your household have health insurance?

24. Do you own or rent your home?

25. How much do you pay per month for your home (rent or mortgage) not

26. Does anyone in your household receive wages and salaries (including sel-employment)?

27. Does anyone in your household receive Supplemental Security Income (SSI; disability benefits)?

28. Does anyone in your household receive Social Security?

29. Does anyone in your household receive General Assistance?

30. Does anyone in your household receive Minnesota Family Investment Plan (MFIP)?

31. Does anyone in your household receive pension or retirement?

32. Does anyone in your household receive unemployment payments?

33. Does anyone in your household receive Minnesota Care?

34. Does anyone in your household receive child support or alimony?

35. Does anyone in your household receive Veteran’s benefits?

36. Does anyone in your household receive Medical Assistance?

37. Does anyone in your household receive food stamps?

38. Does anyone in your household receive Housing Choice Voucher (Section 8)?

39. Other sources of income your household receives?

40. Do you plan to move in the next few years?

41. Why do you intend to move?

42. Where do you intend to move?

43. What city or suburb of Hennepin County do you plan to live in?

44. Which income category comes closest to your total household income before taxes (gross income)?

45. How did you hear about our servcies?

Please enter date of completion: *