Neighbor Next Door Survey
Please note the purpose of this survey is to collect information on 6th District residents or others that may need assistance/resources or information concerning the coronavirus pandemic.
Do you need assistance with bills due to the coronavirus?
Clear selection
What is your household income?
Are you a small business owner?
Clear selection
If you have children or other dependents under your care: What is your family situation? Single mom, single dad, two parents, raising own children and children of others, raising children of other family members, foster parent(s), shared custody, etc.?
What is your marital status?
Clear selection
What is your zip code?
Do you have access to the internet?
Clear selection
Do you have access to reliable telephone service?
Clear selection
Would you like help with your job related activities due to COVID-19?
Clear selection
What is your housing status? Do you own, rent, stay with family/friends, homeless, short-term, nursing home, assisted living, halfway house, etc.?
Do you, or someone in your household have special needs?
Are you a small business owner?
Clear selection
Do you have health insurance?
Clear selection
Do you have any symptoms related to COVID-19? If yes, explain.
What is your age and the ages of anyone else in your household?
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