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