Community Assessment Tool

COMMUNITY ASSESSMENT TOOL

COMMUNITY _______________________________ DATE __________________

I. PEOPLE

A. Vital and demographic statistic

1. Population density ____________________________________________

2. Population composition ________________________________________

3. Population characteristics

a. Mobility ______________________________________________

b. Socioeconomic status ____________________________________

c. Employment status ______________________________________

d. Years of school completed ________________________________

e. Marriage rate __________________________________________

f. Divorce rate ___________________________________________

g. Dependency ratio _______________________________________

h. Fertility rate ___________________________________________

4. Mortality characteristics

a. Crude death rate ________________________________________

b. Infant mortality rate _____________________________________

c. Maternal mortality rate __________________________________

d. Age-specific death rate __________________________________

e. Leading causes of death __________________________________

5. Morbidity characteristics

a. Incidence rate (specific disease) _____________________________

b. Prevalence rate (specific disease) ____________________________

B. History of community (i.e. founding growth)__________________________

C. Ethnic origin __________________________________________________

D. Values, attitudes, and norms _____________________________________

E. Family systems

1. Types of families (i.e., head of household)______________________

2. Number of children per family______________________________________

F. Housing (types available by percent, condition, percent rented, percent owned)

II. ENVIRONMENTAL

A. Physical

1. Natural resources _________________________________________

2. Geography ______________________________________________

3. Climate _________________________________________________

4. Terrain _________________________________________________

B. Biological and chemical

1. Animal reservoirs or vectors ______________________________________

2. Toxic substances ______________________________________________

3. Food supply __________________________________________________

4. Pollutants ____________________________________________________

5. Flora and fauna _______________________________________________

6. Is this a predominately urban, suburban, or rural community? ___________

Norfolk State University -- Department of Nursing

III. SYSTEMS

A. Health__________________________________________________________

1. Preventative health care practices and facilities (lists) _________________

____________________________________________________________

2. Treatment health care facilities (i.e., acute care, medical and surgical hospitals) list

____________________________________________________________

3. Rehabilitation health care facilities (i.e., alcoholism) list

____________________________________________________________

4. Long-term health care facilities (list)________________________________

____________________________________________________________

5. Respite care services for special education groups (list)________________

____________________________________________________________

6. Hospice care services__________________________________________

____________________________________________________________

7. Catastrophic health care facilities and services ______________________

____________________________________________________________

8. School health services (what and how provided) _____________________

____________________________________________________________

9. Occupational health services ____________________________________

____________________________________________________________

10. Sanitarian services ____________________________________________

____________________________________________________________

11. Health work force (population rations)______________________________

____________________________________________________________

12. Health education activities _______________________________________

____________________________________________________________

13. Methods of health care financing (approximate percent)

a. Private pay ______________________________________________

b. Health insurance _________________________________________

c. HMO ___________________________________________________

d. Medicaid/Medicare ________________________________________

14. Prevalent diseases and conditions (list) ______________________________

______________________________________________________________

15. Linkage with other systems _______________________________________

______________________________________________________________

16. Health care resource overall availability ______________________________

______________________________________________________________

17. Health care resource overall utilization________________________________

_______________________________________________________________

Norfolk State University -- Department of Nursing

B. Welfare

1. Official (public) welfare resources (list)

a. General (i.e., Department of Social Services) _____________________

__________________________________________________________

b. Safety and protection (i.e., fire department) _______________________

__________________________________________________________

2. Transportation resources (public and private) ___________________________

3. Facilities to meet needs (i.e., shopping areas and public housing)____________

_______________________________________________________________

4. Resource accessibility _____________________________________________

5. Resource utilization _______________________________________________

_______________________________________________________________

C. Education

1. Public educational facilities (i.e., schools, colleges)

_______________________________________________________________

2. Private educational facilities (list) _____________________________________

________________________________________________________________

3. Libraries (list) ____________________________________________________

________________________________________________________________

4. Educational services for special populations _____________________________

a. Pregnant teens ______________________________________________

b. Adults _____________________________________________________

c. Developmentally disabled children _______________________________

d. Other ______________________________________________________

___________________________________________________________

5. Resource accessibility ______________________________________________

6. Resources utilization _______________________________________________

________________________________________________________________

D. Economic

1. Major industry and business (list) _____________________________________

________________________________________________________________

2. Banks, savings and loan, credit unions (lists) ____________________________

________________________________________________________________

3. Major occupations (list) _____________________________________________

________________________________________________________________

4. General socioeconomic status of population _____________________________

________________________________________________________________

5. Median income ___________________________________________________

6. Percent of population below poverty level _______________________________

________________________________________________________________

Norfolk State University -- Department of Nursing

E. Government and Leadership

1. Elected (official) leadership (list with title)________________________________

________________________________________________________________

2. Nonofficial leadership (list with title affiliations)____________________________

_________________________________________________________________

3. City offices (location, hours, services)___________________________________

_________________________________________________________________

4. Accessibility to constituents ___________________________________________

_________________________________________________________________

5. Support of community resources_______________________________________

_________________________________________________________________

F. Recreation

1. Public facilities (list) _________________________________________________

_________________________________________________________________

2. Private facilities (list) ________________________________________________

_________________________________________________________________

3. Recreational activities frequently utilized (list) _____________________________

_________________________________________________________________

4. Leisure activities frequently utilized (list)_________________________________

_________________________________________________________________

5. Coordination with educational recreation facilities and programs

__________________________________________________________________

6. Programs for special populations groups

a. Elderly__________________________________________________________

b. People who are handicapped ________________________________________

___________________________________________________________________

c. Other ___________________________________________________________

7. Resource accessibility ________________________________________________

8. Resource utilization ___________________________________________________

G. Religion

1. Facilities by denomination (list)____________________________________________

____________________________________________________________________

2. Religious leaders (list) __________________________________________________

____________________________________________________________________

3. Community programs and services ________________________________________

____________________________________________________________________

4. Resource accessibility __________________________________________________

____________________________________________________________________

5. Resource utilization ____________________________________________________

____________________________________________________________________

Norfolk State University -- Department of Nursing

IV. COMMUNITY DYNAMICS (describe)

A. Communication (diagram and describe

1. Vertical (community to larger society)

_____________________________________________________

2. Horizontal (community to itself)

_____________________________________________________

3. Specific resources (i.e., TV, radio, newspapers)

_____________________________________________________

V. MAJOR SOURCES OF COMMUNITY DATA

A. Government (i.e., local health department, city office)

B. Private (i.e., chamber of commerce)

Norfolk State University -- Department of Nursing