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)