NPLLC Resident Survey Form (COVID-19)
Community and residential preparedness survey. All responses are anonymous and will only be used to identify residential needs within this community.
What area/community do you live in? *
How many weeks could you financially sustain your household if your workplace closed and you received no additional pay? Think carefully about the collective needs of your household (e.g. food, pets, utilities, toiletries, etc.). *
Does your household include grade age students affected by the Distance Learning Model. *
If you answered yes to the last question. Quickly explain how your child is affected by the Distance Learning Model. *
What local resources would you use if you needed help with the items below? Check all that apply. *
None
Faith-Based (e.g. churches)
Community (e.g. neighbors, non-profits)
Government (e.g. Dept. of Health)
Corporate (e.g. healthcare/local businesses)
Friends/ Family
Not Sure
Stress/Emotional Support
Transportation
Food/Water
Healthcare
Utilities
Childcare
Adultcare
Other: Please Specify
On a scale from 1 to 5 (where 1 is least concerned with and 5 is most concerned with). Rate the issue area that you are most concerned with in terms of providing for you/your family's needs. *
1
2
3
4
5
Food
Medicine
Shelter
Internet
Access to Medical care
Access to Mental healthcare
Voting/Elections
Employment/Unemployment
Scams
Television
Radio
Contact with family/friends
Mobile/Cell
Safety
Other
In the next 60 days, are you worried about your ability to find or purchase food/water/cleaning supplies/medical supplies for yourself or people in your household? *
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