COVID-19 / Coronavirus Needs Assessment
This is how we bridge the gap and bring the community what it really needs. We take the security of your information very seriously. This online form is completely safe and secure and your information will not be shared with anyone. This Google Form is HIPAA compliant.
Email *
Phone *
Name *
Date of Birth
MM
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DD
/
YYYY
Address *
City *
State *
Zip Code *
County *
Employment Status *
Annual Gross Household Income *
Total Number of People in Household *
How many people are Ages 0-5? *
How many people are Ages 6-12? *
How many people are Ages 13-17? *
How many people are Ages 18-24? *
How many people are Ages 25-35? *
How many people are Ages 36-59? *
How many people are Ages 60-64? *
How many people are Ages 65+? *
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