COVID-19 Community Needs Assessment Survey
What is the CURRENT work status of ALL household members who were employed prior to the COVID-19 pandemic? Check all that apply.
An essential worker, no changes
Returned to work Phase 1
Returned to work Phase 2
Working from home/remotely/virtually
Reduced hours
Unemployed/Laid off
For any household member that is currently unemployed or laid off, what industry do they work in? ADULT ONE
Accommodation and Food Service
Administrative and Support Services
Agriculture, Forestry, Fishing, and Hunting
Arts, Entertainment, and Recreation
Construction/Utilities
Educational Services
Finance and Insurance
Health Care and Social Assistance
Information
Management of Companies and Enterprises
Manufacturing
Mining
Professional, Scientific, and Technical Services
Public Administration (Including Government)
Real Estate and Rental and Leasing
Retail Trade
Transportation and Warehousing
Unclassified
Wholesale Trade
Other Services
For any household member that is currently unemployed or laid off, what industry do they work in? ADULT TWO
Accommodation and Food Service
Administrative and Support Services
Agriculture, Forestry, Fishing, and Hunting
Arts, Entertainment, and Recreation
Construction/Utilities
Educational Services
Finance and Insurance
Health Care and Social Assistance
Information
Management of Companies and Enterprises
Manufacturing
Mining
Professional, Scientific, and Technical Services
Public Administration (Including Government)
Real Estate and Rental and Leasing
Retail Trade
Transportation and Warehousing
Unclassified
Wholesale Trade
Other Services
For any adult in the household whose workplace is still closed OR still on laid off/furlough because of COVID-19, are they expected to return to work by July 31, 2020?
Yes
No
Unsure
If your household had a loss of income since March 13th, what was the reason(s)? Select all that apply.
Workplace closed temporarily because of stay-at-home orders
Workplace went out of business/closed permanently because of COVID-19 pandemic
Laid off due to COVID-19 pandemic
Work hours and/or salary was reduced due to COVID-19
Cannot work because I am sick with COVID-19 or caring for someone with COVID-19 or on ordered quarantine
Cannot work because I have to care for children not in school or day care because of COVID-19 related closures
Cannot get to my job because of public transportation shutdowns/limited schedules
Providing financial help to someone else
Other
If anyone in your household applied for unemployment benefits since March 13, 2020, how long did it take to receive the first benefit/payment?
1-2 weeks
2-4 weeks
Over 1 month but less than 2 months
Over 2 months but less than 3 months
More than 3 months
Still waiting on benefits
What, if any of these actions have you taken to make sure you have enough money on hand for basic needs?
Reduced food spending
Stop saving for retirement
Use a credit card instead of cash/debit card
Borrowed money from friend/family member
Skipped/stopped paying bills (e.g. rent/mortgage, utilities, credit card, car, insurance)
Stopped paying child support or alimony/spousal maintenance
Cut back on recreational expenses
Took on additional work
Took out a loan
None
Back
Next
How confident are you that your household will be able to afford the kinds of food you need for the next four weeks?
Not at all confident
Somewhat confident
Moderately confident
Very confident
If you did not have enough to food eat or not the kind of food you wanted to eat since COVID-19, why? Choose all that apply.
Couldn’t afford to buy more food
Couldn’t get out to buy food (e.g. didn’t have transportation, or mobility or health problems that prevented you from getting out)
Afraid to go or didn’t want to go out to buy food
Couldn’t get groceries or meals delivered to me
The stores didn’t have the food I wanted
Not applicable
SINCE COVID-19, my household accessed the following resources to meet our food/nutritional needs?
WIC
SNAP/Food Stamps
School-based free/reduced lunch or other programs aimed at children
Local food pantry or food bank or dairy drive-thru
Community meal program or soup kitchen
Home-delivered meal service like Meals on Wheels
Other community program
Family, friends, or neighbors
None
Back
Next
Does anyone in your household have any of these underlying health conditions? Check all applicable.
Asthma
Dementia
Diabetes
High Blood Pressure/Other cardiovascular disease
Immunocompromised conditions
Kidney disease
Liver disease
Lung disease/COPD
Obesity
None
Over the last 7 days, how often have you felt nervous, anxious, or on edge OR not able to stop or control worrying OR felt down, depressed, or hopeless OR have little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
What type of medical coverage do you have?
Medicaid
Medicare
Health Insurance
No Health Insurance
Since the onset of the COVID-19 pandemic, did you DELAY getting routine medical, dental, or mental health care?
Yes, Medical Care
No, Medical Care
Yes, Dental Care
No, Dental Care
Yes, Mental Health
No, Mental Health
Since the onset of the COVID-19 pandemic, did you need medical, dental, or mental health care but DID NOT GET IT?
Yes, Medical Care
No, Medical Care
Yes, Dental Care
No, Dental Care
Yes, Mental Health
No, Mental Health
Back
Next
What is your zip code?
What is your housing situation?
Own, no payments
Own, pay mortgage or loan (including home equity loan)
Rent-to-Own
Rent
Homeless
Other
HOMEOWNERS - Check all that apply.
My mortgage is paid up to date
My mortgage payment is past due
My mortgage payment is deferred/waived
My school or property taxes are paid in full or in escrow
My school or property taxes are past due/delinquent
My mortgage is currently in forbearance
RENTERS - Check all that apply.
My rent is paid up to date
My rent payment is past due
My rent payment is deferred/waived
I am at risk of eviction for nonpayment of rent after August 31, 2020.
How confident are you that your household will be able to pay your next rent or mortgage payment on time?
No confidence
Slight confidence
Moderate confidence
High confidence
Payment is/will be deferred
UTILITIES - Check any and all utility bills that are past due.
Heat
Electric
Cable
Internet
Phone - Landline
Phone - Cellular/Mobile
How confident are you that your household will be able to pay all your utility bills on time next month?
No confidence
Slight confidence
Moderate confidence
High confidence
Back
Next
How has the COVID-19 pandemic affected how any K-12 grade children in your household received education? Select all that apply.
Classes normally taught in person at the school were cancelled
Classes normally taught in person moved to a distance-learning format using online resources, either self-paced or in real time
Classes normally taught in person moved to a distance-learning format using paper materials sent home to children
Classes normally taught in person changed in some other way.
There was no change because schools did not close
How many people in your household attend school?
How many people in your household work from home?
Does each person, either schooling or working from home, have their own computer, laptop, or chrome book?
Yes
No
How often is a computer, laptop, or chrome book available to children for educational purposes?
Always available
Usually available
Sometimes available
Rarely available
Never available
The computer, laptop, or chrome book used for education is:
Provided by the children’s school or school district to use outside of school
Provided by someone in the household or family, or it is the child’s
Provided by another source
How reliable is your household internet connection?
Always reliable
Usually reliable
Sometimes reliable
Rarely reliable
Never reliable
What type of internet connection does your household have?
Broadband (e.g. Spectrum, OEConnect)
DSL (e.g. Verizon, Frontier)
Satellite (e.g. HughesNet, Viasat, DishNET)
Cellular Data/Mobile Wireless (e.g. AT&T)
Dial-Up (e.g. EarthLink)
Do not have home internet connection
Please note any other stressors you are experiencing as a direct result of COVID-19.
Submit
Should be Empty: