Tse Dáá K'áán (Hogback) Chapter Community Assessment Survey

In order to make sure that choices are based on and responsive to community participation, the Community Land Use Planning Committee (CLUPC) places a strong emphasis on a community-driven approach to land use planning. While CLUPC works closely with local governments to make choices, it emphasizes that community members must be included in evaluations and offer feedback prior to decisions being made. CLUPC carries out a Community Assessment Survey in order to help with this.

The CLUPC President announces each meeting, which is open to the public, during the regular chapter meetings.

Kindly allocate the next fifteen to twenty minutes to complete the whole Community Assessment Survey. All residents who live in Tse Dáá K'áán Chapter area and registered voters must can participate in this survey. 

Thank you,
CLUP Committee Members

ALL information is confidential and will not be shared. 

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Email *
Name *
Email Address *
Address (P.O. Box or street number and Road, City, State, Zip Code) *
Cell *
Do you have a Land Line? If yes please submit your land line number? If no enter in "N/A" *
Do you live in Tse Dáá K'áán (Hogback) community? *
Required
Are you a Tse Dáá K'áán (Hogback) Registered Voter?  *
Check if the following are needed for you or your family (Check all that apply):
 *
Required
Please list any additional needs you or your family have that were not listed above. (if none put N/A)
 *
Check how much of a problem, the following barriers are to you and your family in seeking/gaining assistance with your basic needs.
 *
Not a problem
Somewhat of a problem
A big problem
Can’t afford fees/costs of assistance
Not eligible/Don’t qualify for assistance
No transportation to/for assistance
Don’t know where to go for help
Pride (Don’t want to ask for help)
Programs/Services not available in my area
No childcare while receiving/obtaining assistance
Prior bad experience with service/program
Have to work during service hours
Health/Disability
None
Household number and composition 
(How many people live your home?)
 *
0
1
2
3
4
5
6
7
Elderlies (55+)
Adult (25-54)
Young Adult (18-24)
Children (5-17)
Toddlers (2-4)
Infant (0-1)
Household number and composition
 *
0
1
2
3
4
5
6
7
Head Start
Primary School
Middle School
Junior High School
High School
College
Household number and composition
 *
0
1
2
3
4
5
6
7
Male Elderlies (55+)
Male Adult (25-54)
Male Young Adult (18-24)
Male Young Children (5-17)
Male Toddlers (2-4)
Male Infant (0-1)
Household number and composition
 *
0
1
2
3
4
5
6
7
Female Elderlies (55+)
Female Adult (25-54)
Female Young Adult (18-24)
Female Young Children (5-17)
Female Toddlers (2-4)
Female Infant (0-1)
What is your Employment Status?
 *
What are your barriers to employment? 
(Check all that apply)
 *
Required
Do you have reliable Transportation?
 *
What are your barriers to reliable transportation? (Check all that apply)
 *
Required

What do you feel are the biggest problems facing adults in the community?

(Check all that apply)

 *
Required

What do you feel are the biggest problems facing youth (ages 5 to 17) in the community? 

(Check all that apply)

 *
Required
Do you have a Home Site Lease? *

SUSTAINABLE HOUSING

Are your housing conditions adequate?

 *

SUSTAINABLE HOUSING

Do you own your home?

*

SUSTAINABLE HOUSING

Type of residence?

*

SUSTAINABLE HOUSING

Type of home dwelling?

 *

SUSTAINABLE HOUSING

When was your home built/purchased/leased?

 *

SUSTAINABLE HOUSING

What are your major housing concerns? 

(Check all that apply)

 *
Required

SUSTAINABLE HOUSING

Check if you have:

(Check all that apply)

 *
Required

Demographics

Age Group (your age group)

 *

Demographics

Martial Status

 *

Demographics

Race

 *

Demographics

Gender

*

Demographics

Number in Household

 *

Demographics

Highest School Completed

 *

Demographics

Main language spoken at home

 *

Demographics

Household Income

 *

Demographics

Are you disabled?

*

Demographics

Are you a veteran?

*

Do you own a business?

 *

Does anyone in this household have a grazing permit in Hogback?

 *

What livestock do you have?

 *
Required

Is the livestock taken between at least two seasonal camps?

*

Does your family maintain a field for your livestock?

 *

Farming

What size is your farmland?

List the types of crops you grow.

(or list N/A)

 *

Does your farm have irrigation?

 *

Do you have running water in your home?

 *

Is your home wired for electricity?

 *

What type of power do you have?

 *

How do you heat your home?

 *
Required

The majority of the time, where does your family member go to buy…? (name a community, town or city)

GAS

 *

The majority of the time, where does your family member go to buy…? (name a community, town or city)

FOOD

 *

The majority of the time, where does your family member go to buy…? (name a community, town or city)

CLOTHNG

 *

The majority of the time, where does your family member go to buy…? (name a community, town or city)

ENTERTAINMENT

*

Do you think we need a community cemetery?

 *

If yes, where would you put a community cemetery?

*

What kind of services do you feel are needed in your community?

 *

Do you think there is land available for these types of services? Please comment:

 *
Thank you for taking this survey and contributing to the CLUP Committee. 

Please share any other comments for the CLUP Committee on how what you would like in your community or how to improve your community.   *
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