Black Policy Lab "COVID while Black and Queer" Survey
From trying to get testing to being misinformed about COVID, the Black Policy Lab and the National Black Justice Coalition (NBJC) are gathering our experiences during 2020 COVID-19. Please take a moment to share. THIS INFORMATION IS COMPLETELY CONFIDENTIAL AND PROVIDING YOUR NAME IS OPTIONAL.

Be as safe as you can be!

Black Policy Lab + Team NBJC
Email address *
Name (Optional)
Your answer
What is your age? *
Where are you located? *
Please List City, State
Your answer
What is your gender? *
* Cisgender means your gender matches the sex you were assigned at birth, ex: a cisgender woman was assigned female at birth. It is often abbreviated to “cis.”
What is your sexual orientation? *
Are or were you a full-time or part-time student during the current Spring 2020 Semester? *
If you answered 'Yes' to Question 7, have your studies been interrupted by COVID-19?
If Yes, how?
Your answer
Since COVID-19, have you been able to work (paid employment) from home? *
If you have experienced a COVID-19 related employment change, please tell us more about what has happened and how it affects you:
Your answer
If "No" what is your job?
Do you currently have a friend/family member who is in jail or prison? *
Before COVID-19 did you have a primary care physician? *
Are you living with HIV/AIDS? *
If so, do you have access to a primary care physician?
If you have a pre-existing condition(s) what is it? (ex: asthma, COPD, etc.)
Your answer
How has your life changed since the introduction of COVID-19? *
Your answer
At any point, did you feel you had COVID symptoms? *
If you answered yes, what were the symptoms?
Your answer
Have you gotten tested for COVID-19 *
If yes, how difficult was it to get a test?
If yes, have you been tested more than once?
If no, did you try to get tested?
IF YOU WANTED TO GET TESTING BUT DIDN'T, WE WANT TO HEAR FROM YOU
How many times did you try to get testing?
If you tried to get testing, why couldn't you get testing?
Do you know anyone close to you that tried to get testing but was denied? *
How many people are in your home? *
Have the "basics," like housing or food, been a concern? *
Is there a story, feeling or thought you want to share about this moment?
Your answer
Who/what is your support system right now? (check all that apply) *
Required
We honor those who have transitioned. Is there anyone you want us to remember?
Your answer
Is there anyone you want us to pray for/send good vibes to?
Your answer
Please use this space to share concerns that you'd like to see prioritized in light of this epidemic.
Your answer
Check here if interested in being a part of a virtual Black Policy Lab session to discuss and design responses to "COVID while Black and Queer"
THANK YOU!
Launched in 2018, Black Policy Lab creates space for experts, leaders and community to design policies for Black communities to thrive, succeed and be whole. The National Black Justice Coalition (NBJC) is a civil rights organization dedicated to empowering Black lesbian, gay, bisexual, and transgender people.
Submit
Never submit passwords through Google Forms.
This form was created inside of Pink Cornrows. Report Abuse