Jennings County, IN Current Needs Survey

Jennings County, IN Current Needs Survey

This tool is designed to continuously collect information to identify unmet needs in our local community caused by the coronavirus pandemic. Personal Info will not be released to anyone, for any reason.
Name

First NameLast Name
Age
Email Address

Confirmation Emailconfirm email address
May we contact you?

YesNo
Job/Field of expertise
Educational Level
Employment Status Prior to March 1, 2020

WorkingSelf-employedRetiredUnemployedOther
Current Employment Status

No changeSelf-employed business closureSelf-employed business reductionSalary/wage reduction due to COVID-19Unemployed due to COVID-19 layoffsOther
What should we know about how and why your work is currently impacted? (how long have you been unemployed, how long was your self-employed business closed or reduced etc.)
Residence status

OwnRentLiving with familyLiving with friendsHomeless
Civil Status

SingleMarriedWidowedDivorced
Do you have children?
Childcare situation?
Currently who takes care of your children while you work? Has this changed due to COVID?
Do you need different childcare? If yes, then what kind of you help do you need?
Do you have an adult or senior in your family that needs adult care?
How many live in the household?
Current household monthly income gross
Prior to March 1, 2020 monthly income gross
What monthly bills are you currently paying?

Electricity/gasWaterHouse Rent / MortgageCredit Card loanInsurancePhone(s)InternetOther
What monthly bills are you NOT currently paying due to financial strain?

Electricity/gasWaterHouse Rent / MortgageCredit Card loanInsurancePhone(s)InternetOther
Where do you get your current income or money for daily needs?

Employment incomeRetirement / PensionSocial Security / SSILoansNo incomeOther
Are you currently experiencing financial problems? If yes, please explain and tell us why.
Do you need help in regards to food? If yes, then please explain
Are you having issues related to housing? If yes, please explain and tell us why.
List agencies who are helping your family
SNAP, TANF, WorkOne, Name of Church, Charities, Food pantry, shelter, etc.
Comments/Suggestions/Feedback:
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