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Health Information

Resident Portal

ROSS Program Needs Assessment Survey

147 East Spruce Street
Forest City, NC 28043
828.245.1390
Office Hours: Monday - Thursday
8:00 AM - 4:30 PM
Closed Friday

Fields marked with * must be filled out or form will not submit.

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Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC","selected":true},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","label":"Zip Code","name":"zip-code","className":"d-block","subtype":"text"},{"type":"header","subtype":"h2","label":"Household Information","className":"d-block"},{"type":"radio-group","label":"Are you an adult 18 or older?","inline":true,"name":"adult-18-plus","className":"d-block","values":[{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"radio-group","label":"Are you the head of household?","inline":true,"name":"head-of-household","className":"d-block","values":[{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"radio-group","label":"Does anyone in your household have a physical or mental disability?","inline":true,"name":"household-member-with-disability","className":"d-block","values":[{"label":"Yes","value":"yes"},{"label":"No","value":"no"},{"label":"No Response","value":"no-response"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h2","label":"Community/Household Needs","className":"d-block"},{"type":"header","subtype":"h3","label":"How would you rate the following issues for your household?","className":"d-block"},{"type":"radio-group","label":"Availability of job training opportunities:","inline":true,"name":"job-training-opportunities-availability","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate 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Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Education:","inline":true,"name":"education","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Availability of affordable, reliable child-care services:","inline":true,"name":"Availability-of-affordable-reliable-child-care-services","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Lack of Computer/Digital Literacy:","inline":true,"name":"Lack-of-ComputerDigital-Literacy","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Lack of affordable Internet service:","inline":true,"name":"Lack-of-affordable-Internet-service","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Cost of Living:","inline":true,"name":"cost-of-living","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Income/Wages:","inline":true,"name":"income-wages","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Debt:","inline":true,"name":"debt","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Financial Security:","inline":true,"name":"financial-security","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Availability of Financial Services:","inline":true,"name":"financial-services-availability","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Availability of Financial Counseling:","inline":true,"name":"financial-counseling-availability","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Elderly Living Assistance 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Record:","inline":true,"name":"obtaining-degree-with-criminal-record","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Substance Abuse Services:","inline":true,"name":"substance-abuse-services","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"radio-group","label":"Substance Abuse Treatment:","inline":true,"name":"substance-abuse-treatment","className":"d-block","values":[{"label":"Serious Problem","value":"serious-problem"},{"label":"Moderate Problem","value":"moderate-problem"},{"label":"Not a Problem","value":"not-a-problem"},{"label":"Does Not Apply to my Household","value":"na-for-my-household"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"checkbox-group","label":"What are the things that make it difficult for you or other adults in your household to find and/or keep work? (Check all that apply)","name":"factors-that-make-difficult-to-find-and-keep-work","other":true,"className":"d-block","values":[{"label":"Nothing","value":"nothing"},{"label":"Need Affordable Childcare","value":"need-affordable-childcare"},{"label":"Caring for a Family Member who is Sick or Disabled","value":"caring-for-family-member"},{"label":"Do not Speak English Well","value":"do-not-speak-english-well"},{"label":"Need Computer Training","value":"need-computer-training"},{"label":"Need Transportation","value":"need-transportation"},{"label":"Need Internet access","value":"need-internet-access"},{"label":"Need Job Experience","value":"need-job-experience"},{"label":"Need Job Training","value":"need-job-training"},{"label":"No Job Opportunities","value":"no-job-opportunities"},{"label":"Do not have a High School Diploma or GED","value":"no-high-school-diploma-or-ged"},{"label":"Do not have a College Degree","value":"no-college-degree"},{"label":"Disability","value":"disability"},{"label":"Criminal Record","value":"criminal-record"},{"label":"Child Care","value":"child-care"},{"label":"Transportation","value":"transportation"},{"label":"Don't Know","value":"dont-know"},{"label":"No Response","value":"no-response"}]},{"type":"checkbox-group","label":"Do you or any others in your household have interest in the following? (Check all that apply)","name":"do-you-or-household-members-have-interest-in","other":true,"className":"d-block","values":[{"label":"GED/Adult Education","value":"ged-or-adult-education"},{"label":"Vocational Training","value":"vocational-training"},{"label":"Increasing Income","value":"increasing-income"},{"label":"Getting a Job","value":"getting-job"},{"label":"Getting a Better Job","value":"getting-better-job"},{"label":"Saving Money","value":"saving-money"},{"label":"Eliminating Debt","value":"eliminating-debt"},{"label":"2-Year College","value":"2-year-college"},{"label":"4-Year College","value":"4-year-college"}]},{"type":"checkbox-group","label":"Do you our another adult in your household have difficulty with any of the following? (Check all that apply)","name":"do-you-or-household-member-have-difficulty-with-these-subjects","className":"d-block","values":[{"label":"Reading","value":"reading"},{"label":"Math","value":"math"},{"label":"Speaking English","value":"speaking-english"},{"label":"Reading English","value":"reading-english"},{"label":"Writing English","value":"writing-english"},{"label":"Using a Computer","value":"computer-use"}]},{"type":"checkbox-group","label":"What are the primary health care needs of your household? (Check all that apply)","name":"primary-health-care-needs-of-household","other":true,"className":"d-block","values":[{"label":"None","value":"none"},{"label":"Primary Health Care","value":"primary-health-care"},{"label":"Pediatric (child) Care","value":"pediatric-care"},{"label":"Prenatal (pregnancy) Care","value":"prenatal-care"},{"label":"Dental Care","value":"dental-care"},{"label":"Health Care Education/Prevention","value":"health-care-education-prevention"},{"label":"Nutrition and Exercise Programs","value":"nutrition-and-exercise-programs"},{"label":"Services to help Alleviate Stress, Anxiety, Depression","value":"services-to-alleviate-stress-anxiety-depression"},{"label":"Assistance with Daily Living for Elderly/Disabled Residents","value":"assistance-for-elderly-disabled-residents"},{"label":"Health Screening Services","value":"health-screening-services"},{"label":"Substance Abuse Treatment","value":"substance-abuse-treatment"},{"label":"Stop Smoking Programs","value":"stop-smoking-programs"},{"label":"Stop Drinking Programs","value":"stop-drinking-programs"},{"label":"Transportation to Health Care Services","value":"transportation-to-health-care-services"},{"label":"Don't Know","value":"dont-know"},{"label":"No Response","value":"no-response"}]},{"type":"radio-group","label":"What is your Gender?","inline":true,"name":"your-gender","className":"d-block","values":[{"label":"Identifies as Female","value":"identifies-female"},{"label":"Identifies as Male","value":"identifies-male"},{"label":"Other","value":"other"}]},{"type":"radio-group","label":"What is your age?","name":"what-is-your-age","className":"d-block","values":[{"label":"18-24","value":"18-24"},{"label":"25-34","value":"25-34"},{"label":"35-44","value":"35-44"},{"label":"45-54","value":"45-54"},{"label":"55-64","value":"55-64"},{"label":"65 or Older","value":"65-or-older"},{"label":"No Response","value":"no-response"}]}]