Community Needs Assessment Field Survey

Captures resident demographics, perceived community needs, local asset awareness, and willingness to engage. Designed for planning staff and Community Health Needs Assessment (CHNA) partners conducting door-to-door or event-based field surveys.

About Your Household

• How long have you lived in this community?
  Select the range that best describes your length of residency.
• How many people currently live in your household, including yourself?
  Count all individuals who regularly sleep in your home.
• Does your household include any of the following? (Select all that apply)
  Children under 18 / Adults 65 or older / Individuals with a disability / None of the above
• What is your primary language spoken at home?
  This helps us ensure future outreach materials are accessible to your household.

Top Community Needs

• In your opinion, what are the most pressing needs in this community right now? (Select up to 3)
  Examples: affordable housing, healthcare access, job opportunities, public safety, mental health services, transportation, food access, youth programs, senior services, environmental quality.
• How serious is the lack of affordable housing as a problem in your neighborhood?
  1 = Not a problem at all → 5 = Extremely serious problem
• How serious is access to quality healthcare (including mental health) as a problem in your neighborhood?
  1 = Not a problem at all → 5 = Extremely serious problem
• How serious is economic opportunity (jobs, job training, living wages) as a problem in your neighborhood?
  1 = Not a problem at all → 5 = Extremely serious problem
• Please describe the single most urgent need you or your family faces that is not being met by current services.
  Your specific experience helps planners understand gaps that data alone cannot capture.

Access to Services & Local Assets

• Overall, how easy is it for your household to access the services you need in this community?
  1 = Very difficult → 5 = Very easy. Consider transportation, hours, language, cost, and awareness.
• What is the biggest barrier that prevents you or your household from accessing services? (Select all that apply)
  Cost / Transportation / Language / Lack of awareness / Hours of operation / Distrust / Eligibility requirements / No barrier
• Are you aware of the following local resources in your community? (Select all that apply)
  Community health clinic / Food pantry or food bank / Public library / Workforce development center / Senior center / Youth recreation programs / Mental health or substance use services / None of the above
• If you rated access to services as 3 or below, please tell us more about the barriers you face.
  Specific examples help us identify where investment and outreach are most needed.

Community Strengths & Assets

• How would you rate the overall quality of life in your neighborhood?
  1 = Very poor → 5 = Excellent
• What do you consider the greatest strengths or assets of this community? (Select all that apply)
  Strong neighbors / Cultural diversity / Local businesses / Parks and green space / Schools / Faith communities / Community organizations / Public safety / None identified
• Is there a program, organization, or place in this community that has made a meaningful positive difference for you or your family?
  Naming local assets helps planners understand what is already working and worth sustaining.

Willingness to Engage

• How interested are you in being involved in community planning or improvement efforts?
  1 = Not at all interested → 5 = Very interested
• Which types of engagement would you be willing to participate in? (Select all that apply)
  Community meeting / Online survey / Focus group / Advisory committee / Volunteer / Peer outreach / None at this time
• Would you be willing to be contacted for a follow-up conversation about your responses?
  If yes, a separate, non-anonymous contact form will be provided. Your survey responses remain anonymous.
• Is there anything else you would like community leaders and planners to know about the needs or strengths of this community?
  This is your space to share anything not covered above. All responses are reviewed by the planning team.

Optional Demographics

• What is your age range?
  Optional. Demographic data is collected in aggregate only and cannot be used to identify individual respondents.
• What is your gender identity?
  Optional. Select the option that best describes you, or choose 'Prefer not to say'.
• Which of the following best describes your race or ethnicity? (Select all that apply)
  Optional. Used only for aggregate equity analysis in accordance with CHNA reporting standards.
• What is your approximate annual household income range?
  Optional. Helps identify whether needs vary across income levels. All data is reported in aggregate only.