Please respond to this survey as accurately and as specifically as possible.  Its results will help us determine the focus of our activities so that the most pressing needs of the hungry and homeless in our community may be met.

Organization
Address
Telephone
Name and Position
Date Completed
1.  During what hours are your services available?
2.  Who is eligible for your services? (ages, sex, residence, income requirements)
3. For each of the following services, please indicate whether your clients need the service, whether you provide or arrange for the service, and (if you do not) whether you consider it a major unmet need.
	Needed	Provide/Arrange	Major Unmet Need
Meals
Clothing
Housing Referral
Educational Services
Job Training
Psychiatric Services
Medical Services
Child Care
Counseling Services
Information on Cash
Assistance
Advocacy/Translation
General Info and  Referral
Other (What? _____ ________________ )
4. How many requests are you unable to meet? (List reasons)
Workload/facility at capacity
Agency doesn't provide requested service
Ineligible for services
Other
5. To what agency or group do you refer clients who need:
Shelter
Food
Financial Assistance (rent, utilities)
Clothing
Transportation assistance
Other
6. Have you noticed an increase in the number of clients you have had within the past year?  If so, how large of an increase has it been?
7.  If you answered yes to question 6, how did the increased number of clients affect the operation of your agency?
less services (ex: food, beds) available to clients
sought more funding to deal with increased number of clients
requested/bought more equipment or food for clients
had to turn away clients requesting food
had to turn away clients requesting shelter
reduced hours of operation
ran out of funding, vouchers, tokens
8. What do you think are the greatest needs of this needy population?
9. Do you think expansion of your services could meet some of these needs? (probe method and feasibility) if not, what additional ways do you think could fill unmet needs in the community? (consider public and private resources)