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About Siletz news / (Siletz, OR) 199?-current | View Entire Issue (June 1, 2000)
TRIBAL PROGRAM NEWS SILETZ TRIBAL HEAD START COMMUNITY NEEDS ASSESSMENT This survey will identify needs that exist in our community and determine what programs and services would be relevant for Head Start to offer in the future. Your assistance will help us design programs that meet community needs. Thanks for your input and support. Check One (Optional): Native American Address: Other County: Family Data Two-Parent Household □ Single-Parent Household □ Foster Parent □ Guardiano Total number of household members: Total number of children in family: Age(s) of primary caregiver(s): Age(s) of children: Primary language spoken in the home: Do any children have any condition that may be considered a disability or special need? Yes Economic Information Part-time Not Employed Parent(s) Employed: Full-time Gross Monthly Income: Highest grade completed by caregiver: Does family receive: TANF Food Stamps Do you own or rent your home? Do you have reliable transportation? Yes Do you have a telephone? Yes No No SSI GA Please explain: Other: Transportation Do you have access to public transporation? Please rate the following from highest to lowest priority of need: Adult/Higher Education Health Care Alcohol & Drug Awareness No InTraining/School Child Care Do you have children in child care now? Yes No How would you rate your child care? Poor Good Fair Have you had any problems accessing child care services? Yes Which of the following would best meet your needs: Center Based Employment Literacy Parenting Grandparent □ Yes No What is the hourly/monthly rate? Tremendous No Home Based Head Start 1=highest priority to 14=lowest priority Preschool/Head Start Dental Care Cultural Activities Please rate your level of awareness about the following Head Start services: Very Informed Informed Preschool Education Health Services Special Needs Services Parent Involvement Recreation Nutrition Other: Housing Child Care Not Informed Do you know of children ages 3-4 who are not currently enrolled in Siletz Tribal Head Start? Yes Are any of the children referred to in the previous question disabled? Yes No How many? No What do you see as the greatest need(s) facing families in the community? Employment Health Care Parenting Comments: 12 Education Dental Care Alcohol & Drug Awareness Preschool Nutrition Recreation Child Care Housing Literacy (Please return this form to your area office or mall it to DeAnn Brown, PO Box 549, Siletz, OR 97380)
