Family Assessment Step 1 of 8 12% Your Community/Neighborhood*Select BelowApartmentsNeighborhoodsOtherName of your apartments*Select BelowPark PlaceHuntington MeadowsGarcreek CircleCreekviewThe Terrace at Walnut CreekRosemont at Hidden CreekEagles LandingOak CrestDecker LoftsBridge at Loyola LoftsTumbleweed DriveOtherName of your neighborhood/community*Select BelowColony ParkLakesideAgaveCavalier ParkEast Austin Community HillsLBJAgaveParker StationPecan Mobil Home ParkOak Crest Sun CommunityMobil Loaves and FishesOtherName of your Neighborhood or Community* Head of HouseholdFirst Name* Middle Initial Last Name* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Email* Household Members(Includes everyone living at the same address) Household MemberName* First Last Sex* Male Female Birthdate Month Day Year Relationship Race School Phone* Add household memberRemove household member Household Income Data Household MemberName* First Last Income TypeEnter monthly amount into the appropriate fieldPaycheckTANFUnemploymentFood StampsOtherAdd household memberRemove household memberIf you entered any "other" income, please explain Do you have health insurance?* Yes No Do your working age children work?* Yes No N/A How many hours per week?*Is there someone who takes care of the family/children while you work?* Yes No N/A EducationDo you discuss your goals with your child(ren)?* Yes No Do you discuss your family goals with your child(ren)?* Yes No Did you attend high school?* Yes No Did you graduate?* Yes No Did you achieve a GED?* Yes No Did you attend trade school?* Yes No Did you graduate?* Yes No How many hours did you complete?Did you attend community college?* Yes No Did you graduate?* Yes No How many hours did you complete?*Did you attend college?* Yes No Did you graduate?* Yes No How many hours did you complete?* Community ResourcesDo you shop at the local HEB store in your neighborhood?* Yes No Do you shop at J.D.’s Store in your neighborhood?* Yes No Do you use the community medical clinics?* Yes No Do you shop at your local community shops and/or stores?* Yes No Do your child(ren) attend the neighborhood recreation centers?* Yes No Does your family or children attend the Turner Roberts Recreation Center?* Yes No When your children are not in school, do they participate in after-school activities?* Yes No Family EnvironmentDo you have computers in your home?* Yes No How many?*Is there a study area in your home?* Yes No Do you have cable in your home?* Yes No Do you have internet available in your home?* Yes No Is there a timeframe for studying?* Yes No Do the children receive help with their homework from parent(s) or others?* Yes No Is there a library close to your home?* Yes No Are you aware of resources available outside your home to help the children with their homework?* Yes No Do the children have appropriate environment for doing their homework or studying for tests/quizzes?* Yes No TransportationDo you have transportation?* Yes No How many vehicles?*Is your vehicle insured and inspected?* Yes No Is there a bus system near your home?* Yes No Would you use it?* Yes No Is there carpooling available in your area?* Yes No Would you use it?* Yes No NeighborhoodDo you communicate with your neighbors?* Yes No Is your neighborhood in a high-crime area?* Yes No Do you belong to a neighborhood association?* Yes No Would you be interested in belonging to a community development corporation?* Yes No Do your children associate with the neighborhood children?* Yes No Do you approve of this association?* Yes No Do you feel you have adequate protection from law enforcement?* Yes No PhoneThis field is for validation purposes and should be left unchanged.
