IAA Survey: Covid-19 Pandemic Community Needs

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

IAA meluncurkan survey cepat untuk mengamati isu apa saja yang paling berpengaruh terhadap komunitas pada masa pandemi Covid-19. Survey ini diperlukan untuk mengajukan hibah dari Pemerintah Amerika, yang diharapkan bisa membantu sebagian komunitas mengatasi isu tersebut. Waktu terakhir pengisian survey adalah malam ini, Minggu 12 April 2020, jam 12 PM. SURVEY INI ANONIM.

IAA is conducting a quick survey to see what are the main issue facing the community during this Covid-19 pandemic. This survey is need to apply for grants that hopefully can be beneficial for the community to relief some of the issues. Deadline for survey is Sunday, April 12, 2020. THIS SURVEY IS ANONYMOUS.

Bagian pertama berkaitan dengan informasi tentang diri anda secara umum.

The First section asks about your self in general.

1. Dimana anda tinggal? (Where do you live) *

Washington DC

Prince George County, MD

Montgomery County, MD

Baltimore area

Fairfax County, VA

Arlington County, VA

Prince William County, VA

Loudoun County, VA

Negara bagian lain (Other states)

Negara lain (Other country)

Indonesia

Other:

2. Berapa umur anda? What is your age range? *

< 25

25-40

40-60

> 60

3. Status pekerjaan (Current state of employment) *

Essential Worker

Work from Home

Furloughed

Unemployed

Have income but not enough

Pekerja musiman/Sambilan (Seasonal/Gig economy)

4. Apakah anda termasuk golongan beresiko tinggi berdasarkan panduan CDC? (Are you considered high-risk based on CDC guidelines?)

Tidak (No)

Sulit bernafas (Chronic Respiratory Condition)

Lanjut Usia (Older individuals)

Tekanan Darah Tinggi (High Blood Pressure)

Sistem imunitas terganggu (Immunocompromised)

Penyakit jantung (Serious heart condition)

Diabetes (Diabetic)

Penyakit ginjal/hati (Kidney/Liver disease)

Other:

Clear selection

5. Apakah anda sudah menjalani test untuk coronavirus? (Have you been tested for coronavirus)

Ya (Yes)

TIdak (No)

Clear selection

6. Kalau ya, apakah sudah ada hasilnya (If yes, did you receive the result)

Ya (Yes)

TIdak (No)

Clear selection

7. Jika "Ya", apakah anda sudah mendapat bantuan? (If "Yes", what kind of support did you receive?

Medis (Medical)

Keuangan (Financial)

Administrasi (Administrative)

Belanjaan sehari2/kiriman makanan (Grocery/Food delivery)

Other:

Clear form

Never submit passwords through Google Forms.

This form was created inside of Indonesian American.

Forms