COMMUNITY NEEDS ASSESSMENT FORM

Name of the Student Assessor: __________________________________________ Yr. & Section: __________________

Instructor: _______________________________________ Date: __________________
COMMUNITY HEALTH AND SANITATION SURVEY
Good day!

This survey is being conducted by ____________________________ for _________________________. The results of the survey will be used to make recommendations for
improvement of Youth Center’s health and sanitation programs. Kindly return this form to the persons in charge after completion. Thank you.
Part I. Demographic Information

Please tell us a little information about yourself. This information is anonymous and does not require any identifying information.

Name of the Center: __________________________ Total No. of Population: ___________

Length of Stay in the Center: ___________________ Age: _________ Gender: ___________

Part II. Health and Sanitation Concerns

In this survey, we would like to ask about a variety of health and sanitation issues and your opinions about how important these issues are. Put a check mark on the
appropriate box to indicate the importance of each issue to you.
Importance of the Issue
There is a need for: Not Important Least Important Important More Important Most Important

1. Availability of community health workers

2. Wellness programs for the children
3. Enough supply of drinking water in the center
4. Health awareness and sanitation campaign
5. Availability of healthy foods
6. Adequate sanitation in the center
7. Waste segregation practices
8. Regular garbage collection
9. Hand washing and hygiene management at the center

1. What other kinds of health and sanitation problems have you encountered in the Center?
_________________________________________________________________________________________________________________________________________.
2. Mention some best practices that your center implements in terms of health and sanitation?
_________________________________________________________________________________________________________________________________________.
 COMMUNITY NEEDS ASSESSMENT FORM
Name of the Student Assessor: __________________________________________ Yr. & Section: __________________
Instructor: _______________________________________ Date: __________________

RECREATIONAL CONCERNS SURVEY

Good day!

This survey is being conducted by ____________________________ for _________________________. The results of the survey will be used to make recommendations for
improvement of Youth Center’s recreational programs. Kindly return this form to the persons in charge after completion. Thank you.
Part I. Demographic Information

Please tell us a little information about yourself. This information is anonymous and does not require any identifying information.

Name of the Center: __________________________ Total No. of Population: ___________

Length of Stay in the Center: ___________________ Age: _________ Gender: ___________

Part II. Recreational Concerns

In this survey, we would like to ask about a variety of recreational issues and your opinions about how important these issues are. Put a check mark on the appropriate
box to indicate the importance of each issue to you.
Importance of the Issue
There is a need for: Not Important Least Important Important More Important Most Important

1. Playing grounds are kept clean and safe for the children
2. Youth clubs and organizations in the center (e.g. boy scouts and girl scouts)
3. Availability of recreational facilities (e.g. basketball courts, swimming pool)
4. Interesting and well supervised youth programs in the center
5. Authorities to prohibit all forms of gambling in the center

1. What other kinds of recreational problems have you encountered in the Center?
_________________________________________________________________________________________________________________________________________.
2. Mention some best practices that your center implements in terms of recreational activities?
_________________________________________________________________________________________________________________________________________.
 COMMUNITY NEEDS ASSESSMENT FORM
Name of the Student Assessor: __________________________________________ Yr. & Section: __________________
Instructor: _______________________________________ Date: __________________
MORALS OF CITIZENRY SURVEY
Good day!

This survey is being conducted by ____________________________ for _________________________. The results of the survey will be used to make recommendations for
improvement of Youth Center’s morals of citizenry programs. Kindly return this form to the persons in charge after completion. Thank you.
Part I. Demographic Information

Please tell us a little information about yourself. This information is anonymous and does not require any identifying information.

Name of the Center: __________________________ Total No. of Population: ___________

Length of Stay in the Center: ___________________ Age: _________ Gender: ___________

Part II. Morals of Citizenry Concerns

In this survey, we would like to ask about a variety of moral citizenry issues and your opinions about how important these issues are. Put a check mark on the
appropriate box to indicate the importance of each issue to you.
Importance of the Issue
There is a need for: Not Important Least Important Important More Important Most Important

1. Children to practice their religious belief freely.

2. Children to observe courtesy at all times.
3. Children to follow and observe rules in the center.
4. Children to give priority to persons with disabilities.
5. Children to observe punctuality, promptness and good moral conduct at all
times.
6. Authorities to accept opinions and criticisms positively.

1. What other kinds of moral citizenry problem have you encountered in the Center?
_________________________________________________________________________________________________________________________________________.
2. Mention some best practices that your center implements in terms of moral citizenry?
_________________________________________________________________________________________________________________________________________.
 COMMUNITY NEEDS ASSESSMENT FORM
Name of the Student Assessor: __________________________________________ Yr. & Section: __________________
Instructor: _______________________________________ Date: __________________

ENVIRONMENTAL CONCERNS SURVEY

Good day!

This survey is being conducted by ____________________________ for _________________________. The results of the survey will be used to make recommendations for improvement of environmental programs.
Kindly return this form to the persons in charge after completion. Thank you.
Part I. Demographic Information

Please tell us a little information about yourself. This information is anonymous and does not require any identifying information.

Name of the Center: __________________________ Total No. of Population: ___________ No. of Families living in the House: _________________
Length of Stay in the Center: ___________________ Age: _________ Gender: ___________
No. of Household Members Attending:
____________ Elementary School Gross Annual Family Income: __________________
____________ Secondary School _______________________ Less than 70, 000
____________ College or University _______________________ 70, 000 – 99, 000
____________ Home Study Programs _______________________ 100, 000 – 129, 000
_______________________ 130, 000 – 169, 000

_______________________ 170, 000 and over

Part II. Environmental Concerns

In this survey, we would like to ask about a variety of environmental issues and your opinions about how important these issues are. Put a check mark on the appropriate box
to indicate the importance of each issue to you.
Importance of the Issue
There is a need for: Not Important Least Important Important More Important Most Important

1. Good quality of air in the community

2. Good quality of water in the community
3. No smoking in public areas
4. Community members to practice reduce, reuse, and recycle items
5. An ordinance against throwing away plastic, tin, aluminum or glass containers
6. Implementation of zero waste management programs
7. Gardening of vegetables and flowering plants
8. Promotion of energy saving practices in the community
9. Promotion of tree planting activities
10. Proper disposal of chemicals and other hazardous items

1. What other kinds of environmental problems have you encountered in the neighborhood?
_________________________________________________________________________________________________________________________________________.
2. Mention some best practices that your community implements in terms of environmental concerns?
_________________________________________________________________________________________________________________________________________.