COVID-19 Community Needs Survey

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Please fill out this quick survey so that we can better understand your needs.

Email *

1). In what county do you live? *

Charlotte

Mecklenburg

Halifax

Other:

Required

2). In the next 6o days are you worried about your ability to find and/or purchase food for yourself or people in your household? *

Yes

Required

2a). If you answered no to the question above, please explain. If you answered yes, enter "N/A" *

3) Do you need assistance with your rent/ mortgage or foresee needing assistance in the next 60 days? *

Yes

Required

3a). If you answered yes, to the question above, what is your rent/mortgage monthly obligation? If you answered no, enter "N/A" *

4). Do you foresee needing help with utilities in the next 60 days? *

Yes

4a). If you answered yes, to the question above, please explain. If you answered no, enter "N/A" *

5). Do you need assistance with childcare? *

Yes

5a). If you answered yes to the question above, what are the ages of your children? If you answered no, enter "N/A" *

6). Do you need assistance with transportation to work? *

Yes

7). Do you need help purchasing basic need products? *

Yes

8). Do you need help with prescriptions? *

Yes

9). Do you have the financial resources to pay for medical treatment if you or a family member became ill? *

Yes

10). Do you have any emergency housing repairs? *

Yes

10a). If you answered yes, to the question above, do you own your home? If you answered no, enter "N/A" *

11). Do you have any other needs that were not identified? *

Yes

11a). If you answered yes, to the question above, please explain. If you answered no, enter "N/A" *

Your first and last name (optional)

Your phone number (optional)

Your address (optional)

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