Community Needs Questionnaire

Demographics and General Questions

Participant ID

Current User

Participant Demographics

First Name

Last Name

Preferred Name/Nickname

Last 4 of Social

Including you, how many people are in your household?

Partner

Which area are you in?

Preferred Language of Communication

Birthday

Gender

Marital Status

Race

Ethnicity

Address

City

State

ZIP Code

KY County

KCTCS Education

Are you a student in the KCTCS System?

YesNo

Student Information

At which school are you a student?

Your Student ID

KCTCS Student IDs are usually 9 digits. If your Student ID includes leading 0s, please include them.

Please keep in mind that if you receive a 2. Lookup error when submitting this form that this is due to the fact that the Student ID that you have entered here does not match any Student IDs currently on file in Salesforce.

Contact Information

Providing your contact information will allow up to provide you with information if there are programs that are identified to be of assistance for you.

Your Phone

Your Email

Is it safe to send an email to this email address?

YesNo

Understanding your current situation

Housing

Income

Employment

Health Care Access

Adult Education

Workplace Skills

Money Management

Life Skills

Safety

Mental Health

Food

Transportation

Physical Health

Child Education

Childcare

Substance Abuse

Community Needs Questionnaire

Demographics and General Questions

Income and Current Program Use

Children and General