United Way Of Central Kentucky
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Welcome to United Way of Central Kentucky’s 2-1-1 survey, which will gather information for the implementation of UWCK’s 2-1-1 database. This free community-wide service is only as helpful as the information in our system so we can effectively refer clients to available resources. UWCK’s 2-1-1 service, once live in late 2016, will allow individuals in the five county region to access any resource they are needing via the internet or phone. If you would like to complete this form electronically, you can find it online at http://www.unitedwayck.org/2-1-1. Please answer all 32 questions to the best of your ability. The questions vary between write-in and multiple choice. Also, if you can answer “none” on a question, please answer “none” or “N/A” instead of leaving a question blank. If you have multiple programs for your organization, please list them under question 15. When answering questions 18-25, please notate if the individual programs have procedures that differ from the overall organization. You can also fill out individual surveys for each program. We thank you in advance for your time and patience in sharing information about your services.
United Way of Central Kentucky | 604 N Main Street, Elizabethtown KY 42701 | 270-737-6608 | unitedwayck.org 2-1-1 INFORMATIONAL SURVEY
Section 1: Agency Information:
1. Agency or Coalition Name: Click here to enter text.
2. Is your agency already in the 2-1-1 database? Yes No Do not know
3. Other names or abbreviations for agency: Click here to enter text.
4. Physical Address, City, County, State, and Zip:
Click here to enter text.
5. Phone (central): Click here to enter text. Phone (administrative): Click here to enter text. Phone (fax): Click here to enter text. Phone (other): Click here to enter text.
6. Postal Address, City, County, State, and Zip:
Click here to enter text.
7. Hours of operation: (Administrative): Click here to enter text. (Intake): Click here to enter text.
8. What is the website/URL for your agency? Click here to enter text.
9. What is the primary email address for your agency? Click here to enter text.
United Way of Central Kentucky | 604 N Main Street, Elizabethtown KY 42701 | 270-737-6608 | unitedwayck.org 10. Is your agency currently accepting volunteers? Yes No Volunteer times vary
11. What is your agency type? (please mark yes to all that apply). Government Non-Profit Membership Faith-based Volunteer Private Practice Church Not Classified: Click here to enter text.
Section 2: Contact Information:
12. Name of Agency Director: Click here to enter text.
Phone: Click here to enter text. Email: Click here to enter text.
13. Please list a point-of-contact: Click here to enter text.
Phone: Click here to enter text. Email: Click here to enter text.
14. Please list an alternative point-of-contact: Click here to enter text.
Phone: Click here to enter text. Email: Click here to enter text.
Section 3: Program Information:
15. Please list all services your agency provides: a. Click here to enter text. b. Click here to enter text. c. Click here to enter text. d. Click here to enter text. e. Click here to enter text. f. Click here to enter text. g. Click here to enter text. h. Click here to enter text.
16. Please give a short description of your agency: Click here to enter text.
17. Please mark all of the counties your agency services: Hardin Breckinridge Grayson LaRue Meade
18. Please list the eligibility requirements for services from your agency: Click here to enter text.
19. Please give a short description of your intake procedure: Click here to enter text.
20. Please disclose any fees associated with services your agency provides: Click here to enter text.
21. Please list all forms of payment accepted: Click here to enter text. United Way of Central Kentucky | 604 N Main Street, Elizabethtown KY 42701 | 270-737-6608 | unitedwayck.org 22. Please list all paperwork required to apply for services from your organization: Click here to enter text.
23. Please list all language services or translation services available (English, Spanish, ECT.): a. Click here to enter text. b. Click here to enter text. c. Click here to enter text. d. Click here to enter text.
24. Please list all genders your agency programs serve (if all, list all): a. Click here to enter text. b. Click here to enter text. c. Click here to enter text. d. Click here to enter text.
25. Does your program require a referral from another agency or organization? Yes No Do not know
26. Does your agency offer transportation services to and from your location? Yes No Do not know
27. Is your building compliant with the Americans with Disabilities Act? Yes No
28. Does your agency offer assistance with applications to individuals with special needs? Yes No
29. Are there any restrictions on services offered by your agency? Click here to enter text.
30. Would you like your agency’s information published in the 2-1-1 directory or in United Way of Central Kentucky’s 2-1-1 database? Yes No
31. Thank you for your time and thank you for taking our survey. If there are any comments or suggestions that you would like to leave for us, please leave them below. Click here to enter text.
Please return via email to [email protected].
United Way of Central Kentucky | 604 N Main Street, Elizabethtown KY 42701 | 270-737-6608 | unitedwayck.org