ESSF Survivor's Feedback Form

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Your Views
How did you find the process of accessing the funding?*

Very easySomewhat easyNot sureSomewhat difficultVery difficult
Is there anything about the process or experience of accessing the funding that could be improved?
What did you use the fund for? Please select all that apply*

Home security (e.g. video doorbell)Urgent essentials (e.g. food, clothing)Travel to safe accommodation (e.g. taxi/train to refuge)Moving costs (e.g. removal van when moving to safe accommodation)Other (please secify)
Date/Time of Submission

DayMonthYear
Date
Hour Minutes

To what extent do you agree or disagree that the funding has:*

Rows	Strongly agree	Agree	Not sure	Disagree	Strongly disagree	N/A
Provided you with items to improve your safety at home
Increased feelings of safety for you
Increased feelings of safety for your children
Assisted you in moving to a new location of safety
Had a positive impact on your mental health and wellbeing
Had a positive impact on your physical health
Helped you to manage financial difficulties
Helped you to access education and learning opportunities
Helped you to access employment opportunities

Please briefly describe the difference that this funding has made to your life, if any?
How might things be different for you if you had not received support from this funding?
Is there anything else you would like to tell us about your experience of accessing the funding?
About you
Which district, city or borough do you live in?*

BasildonBraintreeBrentwoodCastle PointChelmsfordColchesterEppingHarlowMaldonRochfordTendringUttlesfordSouthendThurrockPrefer not to say
What is your gender?*
Which age group do you belong to?*

18-2425-3435-4445-5455-6465+Prefer not to say
Which one of the following best describes your ethnic group or background?*

Asian or Asian British - BangladeshiAsian or Asian British - ChineseAsian or Asian British - IndianAsian or Asian British - OtherAsian or Asian British - PakistaniBlack or Black British - AfricanBlack or Black British - CaribbeanBlack or Black British - OtherMixed - OtherMixed - White and AsianMixed - White and Black AfricanMixed - White and Black CaribbeanOtherOther - ArabWhite - BritishWhite - Gypsy / Irish TravellerWhite - IrishWhite - OtherPrefer not to say
Do you consider yourself to have a health condition, disability or impairment? Please tick all that apply.

No impairmentHearing impairment/deafVisual impairment/blindDeafblindMental health needsDrug or alcohol addictionPhysical impairmentLearning difficulties/disabilitiesAutism spectrum disorderPrefer not to say Other (please specify)
Should be Empty:

Please take a few moments to complete this feedback form