Niagara University - COPC - Community Outreach Partnership Program

US Department of Housing and Urban Development (HUD) Executive Director: Jill A. Shuey Faculty Coordinator: Dr. David B. Taylor
	Needs Assessment

NEEDS ASSESSMENT AGENCY INFORMATION FORM PLEASE FILL OUT A FORM FOR *EACH* PROGRAM THAT THE AGENCY OFFERS.
AGENCY SECTION:
NAME OF AGENCY:
AGENCY HOURS:
EXECUTIVE DIRECTOR:

PROGRAM INFORMATION SECTION: PLEASE USE A DIFFERENT FORM FOR EACH PROGRAM THAT YOUR AGENCY OFFERS:
PROGRAM:
PROGRAM HOURS:
PROGRAM DIRECTOR:
PROGRAM CATEGORY:
If Other:

PROGRAM LOCATION:
TELEPHONE NUMBER:
FAX:
EMAIL:
WEBSITE:
# SERVED MONTHLY:
# SERVED YEARLY:
AGES OF PEOPLE YOU SERVE:
SERVICES PROVIDED:

GEOGRAPHIC AREA SERVED: EX. COUNTY, MUNICIPALITIES, CENSUS TRACT

YOUR INFORMATION:
NAME:
PHONE NUMBER:
EMAIL:
COMMENTS: