Economic/Community Development Questionnaire

CDC Survey: Project Hope: The Road To Economic Self Sufficiency

We are trying to receive government funding to assist low income individuals and businesses from rural and urban areas of Low Income/Moderate Income your kind assistance will assist us with trying to reach this goal. Please answer all questions fully, Your kind assistance is appreciated.

“Let Each Man and Each Woman Have The Opportunity To Become Self Sufficient”

Section A - General Resident Information

Name:
Address:
which of the following categories best describes your racially ethnic background? American IndianlAlaskan Native   
Asian 
  
Black 
  
Hispanic   
White 
  
Other 
  

Starting with yourself, indicate the age for each adult member of your household. (Adults are persons age 18 or older).


       Age
You (1)
Household member 2
Household member 3
Household member 4
Household member 5

Starting with yourself, indicate the highest level of education completed for each adult member of your household. (Adults are persons age 18 or older).


  No Highschool   Highschool/GED
You (1)
Household member 2
Household member 3
Household member 4
Household member 5
Indicate the sources of your household income. Check all boxes that apply Wages or pay from a job   
Income from self-employment 
  
Pension   
Social Security retirement 
  
Child support or alimony   
AFDC 
  
General assistance 
  
Supplemental Security Income (SSI)   
Social Security Disability Income (SSDI) 
 
Unemployment benefits 
  
Other (specify) 
  

How long have you been receiving the following types of income?

AFDC
General assistance
Supplemental Security Income (SSI)
Social Security Disability Income (SSDI)
Unemployment benefits
Can you read and write in English? Yes   No   
How would you rate your ability to read and write in English? Good   Fair   Poor   
Do you know how to use a computer? Yes   No   
If so, describe your computer skills.
If not, would you like to learn to use a computer?
you want to learn how to use a computer?
Yes   No   
Why?
Please check the skills you already have?
If so, check all that apply
Word processing   
Spreadsheets 
  
Database   
Other 
  
Would you like to own a business? Yes   No   
No If so, what kind?
Do you already run a business (including out of your home)? Yes   No   
No If so, describe the type of business you run
What is the full name of your place of worship?

Section B - Employment

What is your current employment status? Employed full-time   
     Please list your job title:
     
Employed part-time 
  
     Please list your job title:
     
Self~employed 
  
Unemployed 
  
Have you interviewed for a job in the last 2 years? Yes   No   

If you are currently employed1 please answer the following questions

Were you hired?
Did you prepare a resume to get this job? Do you work with computers?
Did you receive any computer training for this job? Yes   No   
If so, describe?
Is there a different job you would rather be doing? Yes   No   
If so, describe?

If you are not employed, please answer the following questions.

What kind of work are you looking for?
Are you looking for full-time or part-time work?
what additional training do you feel you need to find a job?
What did you do?
Did you work with computers? If so, describe?
Were you a member of any trade organization? Yes   No   
If so, please list the name
Would you participate in learning computer skills or training others if a computer facility was close by? Yes   No   

Section C - Childcare


       Age
Child 1
Child 2
Child 3
Child 4
Child 5
Where do your children 6-12 years old go after school?
Do you believe that your children need after-school activities? If so, describe why?
When do your children have the most free time?
What do you and your children usually do in the evenings?
Do your children take any computer classes or classes that use computers?
Would you take them to a computer center if it was located nearby?
Do you own or rent a home? Yes   No   
If no, would you like to own a home one day?
What are some obstacles to your getting a home?
Do you own a business? Yes   No   
If no, why not?
If you could receive funding to go into business what type of business would you go into?
Would you hire welfare people? Yes   No   
Why ?
Please list and identify the top 5 community problems in your area(community)?
Please list and identify the top 5 economic problems in your area(community)
If you had a magic wand and you could change things to make them better in your community; what recommendations would you make to the federal government and local and state authorities?
Name three people in your community who are doing things to make a difference and please tell us why?
Would you be willing to work with your local community development corporation to make things better in your community. Yes   No   
I reside in the...(area of City or State)