ROSS Needs Assessment UWSV ROSS Needs Assessment Please enter your initials: Are you an adult 18 years or older? Yes No Are you the head of household? Yes No Does anyone in your household have a mental or physical disability? Yes No How would you rate the following issues for your household?Availability of job training opportunities Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Availability of jobs for adults Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Availability of jobs for youth Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Education Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Availability of child-care services Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Lack of computer/digital literacy Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Cost of living Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Income/wages Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Debt Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Financial security Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Availability of financial services Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Elderly living assistance (62+) Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Physical health Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Mental Health Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Seeking employment with a criminal record Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Obtaining a degree/diploma with a criminal record Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Availability of substance abuse services Serious Problem Moderate Problem Not a Problem Does not apply to my housheold Need for substance abuse treatment Serious Problem Moderate Problem Not a Problem Does not apply to my housheold What ar ethe things that make it difficult for you or other adults in your household to find and/or keep work? Check all that apply: Nothing Need affordable childcare Caring for a family member who is sick or disabled Do not speak English well Need computer training Need transportation Need job experience Need job training No job opportunities Do not have a high school diploma/GED Do not have a college degree Disability Criminal record Lack of transportation Don't know Other If you answered other, please specify: Do you or others in your household have interest in the following? Check all that apply: GED/Adult education Vocational training Increasing income Getting a job Getting a better job Computer training Saving money Eliminating debt 2-year college 4-year college Trade school None Other If you answered other, please specify: Do you or another adult in your household have difficulty with any of the following? Check all that apply: Reading Math Writing Speaking English Writing English Using a computer None Other If you answered other, please specify: What are the primary health care needs of your household? Check all that apply: Primary healthcare Pediatric (child) healthcare Prenatal (pregnancy) healthcare Dental care Healthcare education/prevention Nutrition and exercise programs Services to help alleviate stress/anxiety/depression Assistance with daily living for elderly/disabled residents Health screening services Substance abuse treatment Smoking cessation programs Drinking cessation programs Transportation to healthcare services None Other If you answered other, please specify: What is your gender? Identifies as female Identifies as male Other What is your age range? 18-24 25-34 35-44 45-54 55-64 65 or older What is your highest level of education? Did not attend school 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade Graduated from high school 1 year of college 2 years of college 3 years of college Graduation from college Some graduate school Completed graduate school
