Activate Hawaiʻi Aid C✺VID-19 Community Pulse Survey | ⛑️ Request Help
Aloha! The goal of Community Pulse Surveys is to get a sense of who needs support during the Coronavirus public health emergency.
▶▶▶ ONLY ONE ENTRY PER HOUSEHOLD PLEASE.
▶▶▶ BEFORE YOU BEGIN, PLEASE READ THE FOLLOWING DISCLAIMER: By completing this form, you agree to share your information with our partner agencies providing emergency relief and volunteer coordination. Completing the survey will help in deploying resources thoughtfully and strategically. We will do our best to provide assistance to all who participate. BY PROCEEDING, YOU ACKNOWLEDGE THAT YOU UNDERSTAND THIS STATEMENT.
What is your first name?
What is your last name?
What is your cell phone number?
Other than your cell number, is there another number where you can be reached, such as a home phone?
What is your preferred contact method?
By providing us with your contact information and preferred contact method(s), you authorize representatives of Activate Hawaiʻi Aid and our project partners to contact you regarding COVID-19 assistance programs.
All of the above
What is your physical address—street number and name?
Please do not enter post office boxes or general delivery. This information is required.
What is your city?
Other (Please specify below)
What is your zip code?
How many individuals are there in your household?
How many keiki (children under the age of 18) are there in your household?
How many kūpuna (elderly individuals age 62 or older) are there in your household?
How many kūpuna (elderly individuals age 62 or older) in your household are Native Hawaiian?
If you currently receive emergency food assistance from a local food bank, government program, local non-profit, or faith-based organization, please check "Yes" below. (This does not include SNAP benefits.)
If yes, please let us know the source(s).
If you do not currently receive emergency food assistance, would you be interested in learning more about available programs?
If you currently require (or would require) home delivery for food assistance programs, please check "Yes" below.
Please Note: This is ONLY for those who cannot pick up supplies nearby due to mobility, health, or increased risk of complications from COVID-19.
If applicable, please indicate why your household requires home delivery.
I, or someone in my household, is over the age of 60 and at higher risk of contracting COVID-19 according to the CDC.
I, or someone in my household has an underlying health condition such as heart disease, lung disease, asthma, immunodeficiency, diabetes, or another chronic illness and is at higher risk of contracting COVID-19 according to the CDC.
My household has limited access to transportation
Do you currently receive services through either of the following? Check all that apply.
None of the above
If you or others in your household need assistance navigating financial commitments (i.e. rent, mortgage, utilities) due to the Coronavirus health emergency, please check "Yes" below.
Do you have keiki (children ages 2 and up), in your household who would benefit from receiving Keiki Care Packs?
Activate Hawaiʻi Aid schedules islandwide distributions of Keiki Care Packs once per month or every other month. Packs contain non-perishable food stuffs, curated coloring sheets, activities, and resources for kids and young teens to better understand the COVID-19 pandemic, as well as materials to support parents to engage their keiki and cope with the stresses of living through this pandemic.
Yes, I have already participated and have received Keiki Care Packs.
Yes, I am interested in the program but have not yet participated.
Yes, I have keiki but am not interested in participating.
A copy of your responses will be emailed to the address you provided.
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service