Community Needs Assessment Form

Community Needs Assessment Form

{{company_name}}

{{company_address}}

Phone: {{phone}} | Email: {{email}}

Website: {{website}}

Section 1: Demographics

Please provide some general information about your household and community:

1. Your Age Group: {{age_group}}

2. Gender: {{gender}}

3. Highest Level of Education Completed: {{education_level}}

4. Current Employment Status: {{employment_status}}

5. Number of people in your household: {{household_size}}

6. Location (e.g., specific neighbourhood/ward if applicable): {{location}}

Section 2: Health and Well-being

Please rate the following aspects of health and well-being in your community on a scale of 1 (Very Poor) to 5 (Excellent):

1. Access to Quality Healthcare Services: {{healthcare_access_rating}}

2. Availability of Clean Water and Sanitation: {{water_sanitation_rating}}

3. Nutrition and Food Security: {{food_security_rating}}

4. Mental Health Support Services: {{mental_health_rating}}

5. Prevalence of Diseases (e.g., malaria, HIV/AIDS): {{disease_prevalence_rating}}

6. What are the biggest health challenges facing your community? {{health_challenges_open_text}}

Section 3: Education and Skills Development

1. Access to Quality Primary Education: {{primary_education_access_rating}}

2. Access to Quality Secondary Education: {{secondary_education_access_rating}}

3. Availability of Vocational Training/Skills Development Programs: {{vocational_training_rating}}

4. Literacy Levels among Adults: {{adult_literacy_rating}}

5. What improvements are needed in educational facilities or programs? {{education_improvements_open_text}}

Section 4: Economic Opportunities and Livelihoods

1. Availability of Employment Opportunities: {{employment_opportunity_rating}}

2. Access to Financial Services (e.g., loans, savings): {{financial_services_access_rating}}

3. Support for Small Businesses/Entrepreneurs: {{small_business_support_rating}}

4. Prevalence of Poverty: {{poverty_prevalence_rating}}

5. What are the main sources of income in your community? {{main_income_sources_open_text}}

6. What economic improvements would most benefit your household? {{economic_improvements_open_text}}

Section 5: Infrastructure and Environment

1. Condition of Roads and Transportation: {{roads_transportation_rating}}

2. Access to Reliable Electricity: {{electricity_access_rating}}

3. Waste Management and Sanitation Services: {{waste_management_rating}}

4. Environmental Pollution (e.g., air, water, land): {{environmental_pollution_rating}}

5. Access to Public Spaces (e.g., parks, community centres): {{public_spaces_access_rating}}

6. What are the most pressing infrastructure or environmental concerns? {{infrastructure_environment_concerns_open_text}}

Section 6: Safety and Security

1. Level of Community Safety and Security: {{community_safety_rating}}

2. Effectiveness of Local Law Enforcement: {{law_enforcement_rating}}

3. Prevalence of Crime: {{crime_prevalence_rating}}

4. What are your main safety concerns? {{safety_concerns_open_text}}

Section 7: Community Participation and Governance

1. Opportunities for Community Members to Participate in Decision-Making: {{community_participation_rating}}

2. Effectiveness of Local Leadership/Governance: {{local_governance_rating}}

3. Level of Unity and Cohesion within the Community: {{community_unity_rating}}

4. How can community involvement be improved? {{community_involvement_improvements_open_text}}

Section 8: Prioritization of Needs

From the areas discussed, please list the top 3 needs or challenges that you believe require urgent attention in your community:

1. {{priority_need_1}}

2. {{priority_need_2}}

3. {{priority_need_3}}

If your organization, {{company_name}}, were to implement a new program, what area should it focus on to bring the most positive change to your community? {{program_focus_recommendation}}

Section 9: Additional Comments

Please use this space for any additional comments, suggestions, or concerns you may have regarding your community's needs:

{{additional_comments_open_text}}

Thank You

Thank you for taking the time to complete this Community Needs Assessment Form. Your input is invaluable in helping us to better understand and serve the needs of your community.

Signature

Name (Optional): {{respondent_name}}

Date: {{date}}