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Community Service Provider Survey The Self Reliance Foundation is a 501©(3) nonprofit organization. We empower disadvantaged populations by reinforcing each individual’s capacity for self-determination. In pursuit of this mission, SRF has created the Línea Nacional de Recursos Hispanos to support Hispanics throughout the U.S. and Puerto Rico who need public information, education, healthcare, civil services, and referrals to local organizations.. We are currently updating our database of community serving organizations and your participation would help us greatly. If you have questions please call Karen Tibabuzo at (202)661-8093. Otherwise, please fax the completed survey to us at (202) 637-8801, "Attn: Data Manager." You may also email your response to karen@hrn.org or you may post via mail to: Data Manager, Self Reliance Foundation, 1101 Penn. Ave., NW, Sixth Floor, Washington, D.C. 20045 Thank you and we sincerely appreciate your response.
Please provide us with some information about your agency. NAME OF ORGANIZATION_______________________________________________________________ ADDRESS (w/city, state, and zip code:)__________________________________________________________________ Eligibility (clients:) _______________________________________________________________________________ Target Group: ___________________________________________________________________________________ Geographic Area Served (w/state:)____________________________________________________________________ Application Procedures: ____________________________________________________________________________ Hours: _________________________________________________________________________________________
Please describe fees:
Onsite Service: Yes No National Hotline: Yes No Spanish Speaking Staff: Yes No Web Address: __________________________________________________________________________ Organization Type: Non-Profit, For-Profit, Religious, Governmental Administrator’s Title: ____________________________________________________________________ Administrator’s Name: ___________________________________________________________________ Administrator’s Phone(w|area code:)______________________________________________________________________ Administrator’s Fax(w|area code:) ____________________________email:_______________________________________ Hotline: ______________________________________TDD Line:________________________________________________ Spanish Speaking Contact::_________________________________email:______________________________________________ Contact|Intake Phone:__________________________________Contact Title:_____________________________________ Accredited by(please write full name for acronyms:)____________________________________________________________ Your Mission Statement:
Please list all services you offer in each category or simply use this space to list your services. See below for category defs. Basic Subsistence__________________________________________________________________________________________ Consumer Services_________________________________________________________________________________________ Criminal Justice and Legal Services_____________________________________________________________________________ Education_______________________________________________________________________________________________ Environmental Quality______________________________________________________________________________________ Health Care and Counseling__________________________________________________________________________________ Income Security___________________________________________________________________________________________ Individual and Family Life___________________________________________________________________________________ Mental Healthcare and Counseling_____________________________________________________________________________ Organizational|Community Services___________________________________________________________________________ Target Groups____________________________________________________________________________________________ Basic Subsistence:
Basic Subsistence: Programs that furnish
survival level resources including food, housing, material goods,
transportation and temporary financial assistance for low and fixed-income,
indigent, elderly or disabled people who are otherwise unable to
adequately provide for themselves and their families. Also included
are related services that are available to the community at large. Consumer Services: Programs
that provide for the education and protection of individuals, who
purchase, use, maintain and dispose of products and services. Included
are programs that establish and|or enforce pricing policies, credit
reporting and debt collection practices, quality and safety standards
for goods and services and other trade practices that affect the
consumer; programs that provide information and|or counseling to
help consumers manage their finances and make informed credit and
purchasing decisions; and programs that provide access for consumers
to fair hearings, mediation or binding arbitration when they have
complaints regarding consumer products and services and to appropriate
remedies when their complaints are justified. Criminal Justice
and Legal Services:
Criminal Justice and Legal Services:
Programs that promote and preserve the conditions that enable community
residents to live in a safe and peaceful environment through the
enforcement of laws that protect life and property and the administration
of justice according to the principles of law and equity. Included
are crime prevention programs as well as programs that investigate
and make arrests Education:
Education: Programs that provide opportunities
for people in the community to acquire the knowledge, skills, desirable
qualities of behavior and character, wisdom and general competence
that will enable them to fully participate in and enjoy the social,
political, economic and intellectual life of the community. Environmental Quality: Programs
that preserve, protect and, where possible, improve both the artificial
and natural aspects of the physical environment and|or which develop
and implement measures for accident prevention and intervention
in the case of emergencies in order to promote the public health
and safety and enable human beings to live in ecological balance
and harmony with their surroundings. Health Care and
Counseling:
Health Care and Counseling: Programs
whose primary purpose is to help people in the community achieve
and maintain physical well-being through the study, prevention,
screening, evaluation and treatment of people who have illnesses,
injuries or disabilities; and the provision of family planning,
maternity and other services that relate to human reproduction. Income Security: Programs that
provide for the economic needs of the community by helping those
who are able and willing to prepare for and obtain gainful employment;
by securing public assistance and support for the eligible needy;
and by ensuring that retirees, older adults, disabled people and
other eligible individuals receive the social insurance benefits
to which they are entitled. Individual and Family Life: Programs
that promote the personal, social and spiritual development of people
in the community by providing services that replace or supplement
the care and support that is generally available through the family
unit, and by offering social, religious and leisure-time activities
that are personally satisfying and lead to optimal social functioning. Mental Healthcare and Counseling:
Programs that provide preventive, diagnostic and treatment services
in a variety of community and hospital-based settings to help people
to achieve, maintain and enhance a state of emotional well-being,
personal empowerment and the skills to cope with everyday demands
without excessive stress. Treatment may include emotional support,
introspection and problem-solving assistance utilizing a variety
of modalities and approaches, and medication, as needed, for individuals
who range from the severely chronically mentally ill through those
who are experiencing difficult life transitions or who are having
problems in coping with daily living. Organizational|Community Services Programs that provide any of a broad
spectrum of services for the community as a whole including opportunities
for individuals or groups to participate in community improvement
or service projects, to have a voice in the political process, to
have access to information services, or to benefit from the availability
of a variety of services for residents, travelers, newcomers, community
agencies, organizations, businesses and industry. Target Groups: Individuals
who have specific disabilities, medical diagnoses, ethnic backgrounds,
national origins, family relationships, income levels, religious
affiliations, special problems or considerations, or other targeted
Please Fax to (202) 637-8801, Attn:
Data Manager |
Self Reliance Foundation