Organization Completing the Survey___________________________
Date_________ Survey Contact Person_________________________
SANILAC COUNTY NEEDS/PROBLEMS
From
the following list, check 
all the items
that you believe are a need or problem in the County.
For
each problem or need selected, please indicate how serious the need or problem
is by placing a score from one to ten with 1 being the least serious and 10
being most serious.
For
each problem or need selected, please indicate how large the need or problem is
expected to be for the next 12 to 18 months from one to ten with 1 being the
smallest and 10 being the largest.
Lastly,
indicate your assessment of the adequacy of the services available to meet the
expected need or problem selected by choosing one of the assessments:
Inadequate (I) or Adequate (A) or Surplus Services (S).
|
NEED OR PROBLEM |
IS IT A NEED OR PROBLEM?
THAT APPLY. |
RATE HOW SERIOUS? 1= LEAST SERIOUS 10= MOST SERIOUS |
RATE HOW BIG? 1= SMALL 10=LARGE |
SERVICES AVAILABLE? I=INADEQUATE A=ADEQUATE S=SURPLUS |
|
Recreation
Facilities/Programs ·
Youth ·
adult |
___________ ___________ |
|
|
|
|
Crime |
|
|
|
|
|
Affordable Housing |
|
|
|
|
|
Youth Violence/Child Abuse |
|
|
|
|
|
Affordable Medical |
|
|
|
|
|
NEED OR PROBLEM |
IS IT A NEED OR PROBLEM?
THAT APPLY. |
RATE HOW SERIOUS? 1= LEAST SERIOUS 10= MOST SERIOUS |
RATE HOW BIG? 1= SMALL 10=LARGE |
SERVICES AVAILABLE? I=INADEQUATE A=ADEQUATE S=SURPLUS |
|
Poverty |
|
|
|
|
|
Water, Air, Noise Pollution |
|
|
|
|
|
Shortage of Childcare |
|
|
|
|
|
Drug Abuse |
|
|
|
|
|
Inadequate Public Transportation |
|
|
|
|
|
Underemployment (Working Poor) |
|
|
|
|
|
Alcoholism ·
Adolescent · adult |
__________ __________ |
|
|
|
|
Teenage Pregnancy |
|
|
|
|
|
Family Violence/Abuse |
|
|
|
|
|
Unemployment |
|
|
|
|
|
Mental/Emotional Illness |
|
|
|
|
|
Illiteracy |
|
|
|
|
|
Racial Discrimination |
|
|
|
|
|
Affordable Legal Services |
|
|
|
|
|
Substandard Housing |
|
|
|
|
|
Homelessness |
|
|
|
|
|
AIDS |
|
|
|
|
|
Children in Poverty |
|
|
|
|
|
Eldercare |
|
|
|
|
|
School Drop Out Rate |
|
|
|
|
|
Affordable Health Insurance |
|
|
|
|
|
Local Job Availability |
|
|
|
|
|
Delinquency |
|
|
|
|
|
NEED OR PROBLEM |
IS IT A NEED OR PROBLEM?
THAT APPLY. |
RATE HOW SERIOUS? 1= LEAST SERIOUS 10= MOST SERIOUS |
RATE HOW BIG? 1= SMALL 10=LARGE |
SERVICES AVAILABLE? I=INADEQUATE A=ADEQUATE S=SURPLUS |
|
Availability of Life Support (food, utilities, clothing) |
|
|
|
|
|
Foster Care/Child Protective Services |
|
|
|
|
|
Suicide |
|
|
|
|
|
Affordable Dental Care |
|
|
|
|
|
Driving Under The Influence
of alcohol or drugs |
|
|
|
|
|
Affordable Insurance (other
than health) |
|
|
|
|
|
Personal Debt |
|
|
|
|
NEED OR PROBLEM COMMENTS: Please
identify any needs or problems, their seriousness, size and service
availability that are not on the list above.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
BARRIERS TO HUMAN SERVICES
From the following list,
please check all the
items that you believe are reasons why residents of Sanilac County do not
receive needed human services.
|
TYPES OF BARRIERS |
IS IT A BARRIER?
THAT APPLY. |
|
Lack
of Information About Services |
|
|
Lack
of Transportation |
|
|
Cost
of Services |
|
|
Lack
of Child Care |
|
|
Not
Eligible |
|
|
Perception
of High Cost |
|
|
Too
Long To Wait |
|
|
No
Outside Help Wanted |
|
|
Inconvenient
Location |
|
|
Inconvenient
Hours/Days |
|
|
Perception
of Service Quality |
|
|
Prior
Bad Experience |
|
|
Dislike
of Services |
|
|
Confidentiality
Concerns |
|
|
Language
Barrier |
|
|
Lack
of Handicap Access |
|
|
Not
Available In County |
|
SERVICE BARRIER COMMENTS: Please
identify any barriers to county residents receiving needed human services that
is not listed above._________________________________________________________________________________________________________________________________________________________________________________________________
Does your organization have available any documented studies which define Sanilac County needs in any human service category? Yes_____ No _____
If yes, what is the title and date? ___________________________________
Would you share the study with other human service agencies? Yes__ No __
RETURN COMPLETED FORMS TO: Sanilac County United Way,
P.O. Box 245, Lexington, MI 48450-0245 or email to uwsc@greatlakes.net to be received by end
of business July 30, 2004.