Dear Friend,

CAPIC is in the process of doing an area-wide needs assessment to determine what problems and priorities face families we serve. We are asking you to take a few minutes of your time to tell us your story. Your story, along with others, will enable us to determine which programs and resources to pursue over the next 3 years. Our mission is to help enable residents to become self-sufficient and improve their living conditions.

Please complete this form by July 31, 2010.

Sincerely;

Robert S. Repucci
Executive Director
Instructions

Please fill in the blanks, and check off the boxes that are most like your experiences over the past year. Please try to fill out all the areas that pertain to you, so that we can get a complete understanding of your unique story. Please be assured that all information is confidential and will be used only to help us determine the needs of the residents in our service area. Please feel free to leave blank any questions that you would prefer not to answer.
My Story
My Age:
I am:
Gender: Male Female
I had to have someone help me read / translate this survey: Yes No
I live in the city / town of:
I have children living with me.
My Housing: I (select one:) Own
Rent
Live with parents
Share Housing
Live in a homeless shelter
Subsidized Housing		 Other, please specify:
My total annual income last year was: $
(Note: do not use commas, enter 1,000 as 1000)
I am currently: employed
unemployed
recently laid off
retired
disabled
I have trouble obtaining/maintaining employment: Yes No
I receive the following public benifits:
TAFDC Job Training Program Subsidized Child Care
Educational Grants Medicaid Subsidized Housing
Food Stamps Medicare Unemployment
Fuel Assistance Social Security Veterans Benifits
General Relief SSI/DI WIC
My greatest problem(s) is/are:
(check all that apply)
Child Care Employment Mental Health
Immigration Health Saftey
Discrimination Housing Substance Abuse
Domestic Abuse Income Transportation
Education Literacy Food/Nutrition
ESL Other, please specify:
I receive, or have received, the following services from CAPIC:
Head Start Fuel Assistance Family & Community Network
Child Care Summer Camp After-School Services
Weatherization Housing Assistance Domestic Violence Counseling
Workforce Development Responsible Payee Program  

Please check "yes or no" to all questions that apply to you so we can better service your needs. Thank you.
# Question: Yes No
1. I have a high school diploma or equivalency.
2. I would like to attend college or job training.
3. My child / children receive child care.
4. I was enrolled in Head Start as a child.
5. I need pre-school services.
6. My child / children's child care is affordable.
7. I need an after school program for my child/children
8. I need support in adressing my child's behavior.
9. I use public transportation regularly
10. I have transportation to meet my family's needs.
11. I use a bank.
12. I have to borrow money to buy food.
13. I have 3 meals a day.
14. My children and/or I are going hungry.
15. I need assistance to eat healthy.
16. I am concerned about my child's weight/nutrition.
17. I have had to borrow money for transporation.
18. I have had to borrow money for heat related costs.
19. I have money for heating costs.
20. I have had at least one utility shut-off during the past 12 months.
21. I feel safe in my community / neighborhood.
22. I have needed police assistance.
23. I have needed police assistance but did not call.
24. The police responded quickly to my call.
25. I am satisfied with the police department.
26. My children and / or I have been the victim(s) of violence at home.
27. I have sought counseling due to being a victim of violence.
28. The counseling was responsive to my needs.
29. I have sought shelter due to being a victim of violence.
30. I am concerned about a family member's involvement with alcohol/drugs.
31. I have sought professional help due to issues with alcohol and / or drug abuse.
32. There are substance abuse programs in my area that meet my needs.
33. I have health insurance (e.g.: Mass Health).
34. I receive regular physical check-ups.
35. My children receive regular physical check-ups.
36. My children receive regular eye exams.
37. I have been immunized.
38. My children have been immunized.
39. The clinics and hospitals in my area meet my needs.
40. I receive regular dental check-ups.
41. My children have been tested for lead poisoning.
42. I have been affected by a home foreclosue.
43. My landlord is attentive to housing repair needs.
44. I spend 50% or more of my monthly income on rent / mortgage.
45. My house has been tested for lead.
46. Do you feel you are more self-sufficient after your involvment with CAPIC?
47. Are you active in your community?
48. Do you feel CAPIC has helped improve the condition of your life?
Please use the space below to add any additional comments: