We Care Survey
Out of an abundance of concern for the Black community which is stated to be the hardest hit by COVID-19, ABJ Community Services, Inc and The Ancestral Village are asking you to complete the following survey to help us determine your needs during this period of crisis. ABJ does not discriminate on any basis. Your information will remain confidential.
Name:
Full Name
Date:
-
Month
-
Day
Year
Date
Age:
Zip Code:
Gender:
Male
Female
Other
Race:
Black or African American/Afrodescendant
Hispanic
American Indian or Alaska Native
White
Asian
Other
Do you have any health conditions that put you at a high risk for COVID-19?
Asthma
Diabetes
Heart disease
Hypertension
None
Other
Have you been tested for COVID-19, and if so, where did you go to get tested?
How was the test implemented?
Nasal Swab
Blood Test
None
Other
Did you test positive for COVID-19?
Yes
No
What protective measures have you taken?
Self Quarantine
Face Mask
Gloves
None
Other
How many people live in your household?
1
2
3
4
Other
Do you have anyone that can follow up on your well-being if you go to seek care for COVID-19?
Yes
No
Do you personally know someone who died as result of COVID-19?
Yes
No
Do you know anyone who has experienced violence during COVID-19?
Gun Violence
Domestic Violence
Physical Abuse
Bullying
None
Other
Have you lost any of the following due to COVID-19?
Employment
Employees
Business
Housing
None
Other
If you lost employment or your own business as a result of COVID-19, Do you need any of the following support?
Financial Resources
Food Assistance
Utility Assistance
Housing
Counseling/Support Group
None
Other
Did you receive any deferments or governmental benefits during COVID-19?
Car Payment/Insurance
Rent/Mortgage
Utility
Phone Service
SNAP/Food Assistance
Unemployment Compensation
Stimulus
None
Other
Would you like to add anything else?
Follow up
If you have a question about the survey or you need additional support please provide your email and phone number.
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Thank you for taking the ABJ We Care Survey!
Submit
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