Name: Score:

Subject and Course: Year and Section:

Instructor: Date:
Community Needs Assessment Form
1. Name of Community/Institution Being Assessed
_________________________________________________________________________________
_________________________________________________________________________________
2. Venue or Description of the Location
_________________________________________________________________________________
_________________________________________________________________________________
3. Names of Company Leaders and Representatives
_________________________________________________________________________________
_________________________________________________________________________________
4. Description of the Community and Basic Community Statistics
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

I. Community Leaders and Members’ Opinions

1. What activities are usually/currently conducted.
___ Social ___ Educational
___ Spiritual ___ Recreational
___ Livelihood ___ All of the Above
___ Others, please specify __________________________
2. How frequent are the activities being conducted?
___ Weekly ___ Semi-monthly
___ Monthly ___ Semi-annually
___ Annually
___ Others, please specify __________________________
3. Who conducts the activities?
___ Barangay Council ___ Nongovernment Organizations
___ Combination ___ Community/Civic Groups
___ Youth/Students
___ Others, please specify ___________________________
4. What is the rating of the community leaders and members for the following community current
programs? Put a check (/) on your rating for each question using the scale below:
0 - Not in a position to evaluate/No idea at all
1 - Poor/Never
2 - Needs improvement/very seldom
3 - Satisfactory/Seldom
4 - Very satisfactory/Oftentimes
5 - Excellent/Always
 0 1 2 3 4 5

Social Activities (parties, singing/dancing contests, feast day

celebration, swimming, etc.)

Spiritual activities (recollection, retreat, mass, etc.)

Recreational activities (sportsfest, league, etc.)

Educational Activities (seminars, trainings, workshops, etc.)

Livelihood Activities (microfinancing, subsidies, etc.)

Environmental Activities (cleaning, waste management, garbage

collection, etc.)

5. Who are the active participants of the community activities being conducted?
___ Parents ___ Mothers
___ Fathers ___ Youth
___ Students ___ Out-of-school youth
___ Kids
___ Others, please specify ____________________________

Involvement of the Members of the Community in the Project

0 – Not in a position to evaluate/No idea at all
1 – Poor/Never
2 – Needs improvement/Very seldom
3 – Satisfactory/Seldom
4 – Very satisfactory/Oftentimes
5 – Excellent/Always
Rate the following constituents in terms of involvement or participation in community activities. Put a
check (/) on your rating for each questions using the scale below:

0 1 2 3 4 5

Mothers
Fathers
Students
Out-of-School Youth
Kids

1. Who benefits from the activities?

___ Barangay constituents
___ NGOs
___ Others, please specify _______________________
2. What are the facilities available in the community?
___ Library ___ Plaza
___ Sports Center ___ Social hall
___ Day-Care enter ___ Health Center
___ Others/ please specify ________________________

3. What activities are perceived to be mostly needed by the community?

___ Livelihood activities ___ Jobs fair
___ Spiritual Activities ___ Feeding Program
___ Social mobilization
___ Others, please specify ______________________
4. Issues, problems and opportunities present in the community.
___ Family Problem ___ Lack of support for activities
___ Drug Addiction ___ Education
___ Vices ___ Garbage
___ Health ___ Peace and Order
___ Sanitation
___ Others, please specify _____________________________
5. Issues/concerns that the community leaders/members think should be prioritized.
___ Cleanliness ___ Livelihood
___ Peace and Order ___ Sports
___ Others, please specify _____________________________

II. Evaluation by the Team Conducting the Needs Assessment

1. Needs identified by community leaders and members.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2. Current action being taken to meet community needs.
_________________________________________________________________________________
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3. Local resources available to help meet community needs.
___ Human Resources – people with necessary skills.
_________________________________________________________________________________
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___ Financial Resources – financial assets available.

_________________________________________________________________________________
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_________________________________________________________________________________
 ___ Equipment and Materials – all equipment, materials and supplies that will be available to
support the activities.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
___ Community Organizations/Groups – agencies, organizations, firms and institutions within
the community that can be considered assets to the community in same way.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. Name/s of Assessor/Evaluator:
_________________________________________________________________________________

___________________________
Signature Over Printed Name