2020 Mosaic Survey

2020 Participant Survey
Clallam Mosaic was established to empower and to serve individuals with special needs and their families. Like most organizations, we are having to adjust to the challenges of COVID-19. Together we need to develop new ways to meet these challenges. Your knowledge of the community, and experiences with our special community will give us insight into ways we can most effectively meet the needs of participants.

This survey will help us to identify those needs. We greatly appreciate your input and welcome your suggestions. We would like to be able to contact you in a follow-up email or phone call. If this is okay, please include your contact information below.

Thank you for taking the time to fill out this survey and do not hesitate to contact us with any questions or concerns. Our contact information can be found at the end of this survey.
Personal Information:
Name of participant (whether you currently participate in Mosaic programs or not) *

First Name Middle Name Last Name
Name of person completing survey (if different from above)

First Name Last Name
Relationship to participant (check all that apply)

Parent Sibling Friend Caregiver, unpaid Caregiver, paid Other
Age of participant *
Gender of participant *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
E-mail
example@example.com
Questions and Details:
Do you participate in Mosaic activities? *

No Yes, for less than 1 year Yes, for 1 to 5 years Yes, for more than 5 years Not now, but I used to participate in Mosaic (SNAP) programs
Which Mosaic Zoom programs have you attended during the pandemic? *

Animal Adventures Art Capoeira Exercise Mosaic @ Home Activities Reading Rec Club Social Hour Theater Tik Tok MosaicCon None
Which Mosaic programs did you attend prior to the pandemic *

Art Cooking Exercise Reading Rec Club Theater Videography Dances None
Are you currently using Mosaic CGE services? *
Did you receive Mosaic CGE services prior to the pandemic? *
Are you currently a Mosaic Volunteer? *
Were you a Mosaic Volunteer prior to the pandemic? *
Is anyone in your household using P2P services? *
Was anyone in your household using P2P services prior to the pandemic? *
How has Covid19 impacted your participation in programs?
With the current restrictions on gatherings, do you have recommendations for activities that you would benefit from?
What are your ideal Mosaic programs? Are there new programs you would like to see? Are there additional programs that could be implemented during the current Covid19 pandemic? .... Tell us your dreams:
Would you or someone in your household be willing to Volunteer with Mosaic? *
Would you or someone in your household be willing to donate money to Mosaic? *
Would you or someone in your household be willing serve on Mosaic's Board? *
May we contact you to further discuss any questions or concerns you might have? (you must have entered an email address and/or phone number if you wish to be available for further contact) *
If you would like to be added to Clallam Mosaic's email distribution list, please tell us what email you would like added:
example@example.com
Should be Empty: