Little Dixie C.A.A. Consumer Satisfaction Survey

The information contained in this report is strictly for the use of Little Dixie C.A.A. Head Start program as a survey to determine the needs of the low-income residents of Choctaw, Pushmataha & McCurtain Counties.

Resident of: Town/Community                                                               County

Date survey completed: 

Please answer all of the following questions as they pertain to you and your family.

Name (Optional):                                                                                                        Age of parent

1.Marital status of Head of Household:

If single, Head of Household is: 

2.Does your family live:                                                                   Housing, do you:

3.What is your nationality?

4.What language is spoken in your home? 

5.Total number of persons living in your home  
Of this total, how many are between the ages of:

Birth - 2 yrs. 12 months ..................            19 yrs. 0 months - 25 yrs. 12 months.. 

3 yrs. 0 months - 4 yrs. 12 months..            26 yrs. 0 months - 61 yrs. 12 months.. 

5 yrs. 0 months - 7 yrs. 12 months..            62 yrs. 0 months or older....................

8 yrs. 0 months - 18 yrs. 12 months. 

6.Is anyone in your household mentally or physically disabled?
                           If yes, please list below:
Name (Optional)                                                      Disability                                                Age                                         

Name (Optional)                                                      Disability                                                Age 
7.What is the education level of Head of Household? 

Is someone in your household currently enrolled in school full-time? 

8.Would someone in your household like to continue their education?
(Example: GED, College, Vo-Tech, Etc.)

9.Do you feel someone wanting to attend college needs educational counseling or assistance in making applications for loans, scholarships, and grants?

10.Would someone in your family like to improve their reading skills?

11.Is Head of Household unemployed?
Is anyone in household (other than Head of Household) unemployed? 

12.If jobs were available, would you or anyone in your family accept employment?

13.Do you feel more industry is needed in your community?

14.Is more vocational training needed in your community? 

15.What is the source of your family's income:(Please check any that apply)
           Employment                     TANF                                    Veteran's Disability                              Disability                                                  

                Child Support                     Social Security                      Unemployment Benefits                      Other______

16.Please check family's total annual income:

17.Do you have a Head Start program in your community?  

18.What type of Head Start program would you prefer? 

19.If you had a three or four year old child, would you like him/her to attend Little Dixie Head Start?

20.Do you need summer or before/after school child care?

If yes, please specify which 

If no, which daycare do you currently use?   

21.Is someone in your household currently pregnant?                            Age

22.Do you feel your community needs a program that provides recreational activities and serves a balanced meal to low-income children during the summer?   

23.Does your family use public transportation?    

If you do not use public transportation, does your community have public transit available?     

If yes, are the service hours long enough?      

Do you need public transportation?   

24.Do you feel there is a drug/alcohol problem in your community?    

25.Do you feel there is a teen pregnancy problem in your community?    
26.Do you live in substandard housing? 

27.Does your home need weatherizing? 

28.Does your home need repairs?  

29.Would you build a new home if the interest and payment was low enough? 

30.Does your family have adequate housing? 

31.Does your community provide activities/services for senior citizens? 

32.Are you aware of emergency services available in your community? 

33.Does your family currently receive:
                Food stamps                        WIC                TANF

                Medicaid (Children)               SSI                 Housing Assistance

34Please check below all services or programs your family would use if available in your community:
                ​    Job Counseling                       Financial Counseling                       Vocational Training                       Child Support Collection

                    Legal Aid                               Emergency Shelter                          Parenting Skill                               Emergency Clothing 

                    Nutritional Needs                    Emergency Food                            Youth Activities                             Utility Bill Assistance 

                    Referral Services                    In-Home Health Care                      Volunteer Services                         Mental Health Services  

                    Budgeting Skills                     Child Care/Babysitting                     Assistance Filing Taxes                 Senior Citizen Centers

34 Do you need additional information about Head Start?

35 If so, please provide a phone number where you can be reached.

                                                                                                        Thank you for taking our survey!

1488  on 7/2/15
Married Single Divorced Widowed
Male Female
Within city limits Outside city limits
YesNoNot Applicable
Home based programFive day per week center-based programThree - four day per week center-based program