HSM Back to Life

Operation Boots on the Ground

Community Needs Assessment - Field Copy

County: ☐ Aiken ☐ Allendale ☐ Bamberg ☐ Barnwell ☐ Orangeburg   Date: ____________

Volunteer / interviewer: ______________________________   Application ref: __________________

Perspective: ☐ Resident ☐ Business ☐ Church ☐ Nonprofit ☐ Community leader ☐ Other

City/community: ____________________   ZIP: ________   Assessment ref (after entry): __________________

Priority needs

☐ Safe / affordable housing
☐ Food access / nutrition
☐ Transportation
☐ Health care access
☐ Mental health services
☐ Substance-use recovery support
☐ Employment / job access
☐ Workforce training / skills
☐ Child care
☐ Senior / elder support
☐ Disability services
☐ Utilities / basic household costs
☐ Budgeting / credit / financial capability
☐ Education / youth opportunities
☐ Public safety / neighborhood conditions
☐ Legal / documentation assistance
☐ Reentry after incarceration
☐ Domestic violence / family safety
☐ Homelessness / emergency shelter
☐ Internet / digital access
☐ Other

Barriers to getting help

☐ People do not know where to go
☐ Eligibility rules / documentation
☐ Long wait times
☐ Transportation
☐ Service hours do not fit people's schedules
☐ Cost / affordability
☐ Not enough available appointments, beds, slots, or staff
☐ Online / technology barriers
☐ Language / communication barriers
☐ Trust or prior negative experience
☐ Child-care responsibilities
☐ Accessibility / disability barriers
☐ Other

Ease of accessing needed services: ☐ 1 Very difficult ☐ 2 Difficult ☐ 3 Mixed ☐ 4 Accessible ☐ 5 Very accessible

Who should be part of addressing priorities? ☐ Local government ☐ State government ☐ Federal government ☐ Nonprofits ☐ Churches ☐ Businesses ☐ Residents/community ☐ Unsure

What is working well that should be protected or expanded?

What service or resource gaps do you see?

If one practical improvement could be made first, what should it be?

Operation Boots on the Ground

Stakeholder Follow-Up

Business / employer

Hiring needs, skills gaps, or workforce barriers:

Partnership interest / resources that may be available:

Church / ministry

Recurring needs seen among people served:

Partnership interest / outreach capacity / resources:

☐ Request HSM Back to Life Sunday-morning / church leadership presentation   ☐ Request partnership meeting

Optional follow-up contact

Name/organization: __________________________________________

Email: __________________________________   Phone: __________________________

☐ Respondent consents to HSM Back to Life follow-up.

Field standard: ask neutrally, record the respondent's words accurately, distinguish facts from opinions, protect personal information, and enter this form into the digital portal as soon as practical. Do not ask how a person plans to vote or which candidate/party they support.