Richmond Industrial Fire:

Richmond Industrial Fire Community Needs Assessment
the WellBeing Workshop is committed to working alongside community members in Richmond and surrounding commuities that have been impacted by the Industrial Fire as we work to recover from this experience. We would like to understand how our community has been impacted and what the needs of the community are.

Filling out this form is voluntary, and we will not share your responses outside our organization. We will only contact you with your permission.
Age
Gender

MaleFemaleNon-binary
I identify with the following (select all that apply)

Low-income or working classBlackLatino/a/eAsianSouth AsianIndigenous/Native AmericanDisabledImmigrantNon-English speakerEnglish is not my first languageLGBTIAA+
Employment Status

Working full-timeWorking part-timeSelf-employedRetiredUnemployedSSI or SSDIOther
Residence status

OwnRentLiving with familyUnhousedGroup home/Congregate livingOther
I live inside the official evacuation zone:

YesNo
Did you evacuate?

YesNo
What influenced your decision to evacuate? (Select all that apply)

I live in the evacuation zoneI experienced symptoms from plume (coughing, tight chest, burning/watering eyes, wheezing, sore throat, etc.)I, or someone in my household, has underlying health conditionsI was worried about children in my homeI was worried about my petsOther
Where did you stay?

HotelRental (e.g. AirBnB, VRBO, etc.)With friends or familyEvacuation shelterOther
What influenced your decision to stay?(Select all that apply)

I could not afford to leaveI did not think it was dangerousI couldn't take my petsPhysical disabilityMental health (e.g. don't leave home, anxiety, depression, etc.)Fear of losing jobOther
Have you returned home?

YesNo
Why or why not?
Do you have pets?

YesNo
What did you do with your pets during the fire?

None of us leftI boarded themThey stayed with friendsI had to leave them behindI took them with meOther
Do you have concerns about how the fire affected your health?

YesNoNot sure
Please explain
Do you have concerns about how the fire affected the health of your pets?

YesNoNot sure
Please explain
In what ways did the fire negatively impact you?

Financial burdenPhysical healthMental health/stressLoss of income/businessOther
What community supports interest you?

Clean up helpFree clean up kitFree health screeningFree mental health supportFinancial supportHelp with petsInformation about impact of fireFoodAir quality monitoring in your homeOther
I would like to hear from the WellBeing Workshop about community relief efforts.

YesNo
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Are you interested in volunteering in community response?

YesNo
Should be Empty:

Richmond Industrial Fire Community Needs Assessment