Individual Needs Assessment Survey

	Not at all concerned	Slightly concerned	Somewhat concerned	Very concerned	N/A
Members of my household becoming infected by COVID-19	Members of my household becoming infected by COVID-19 Not at all concerned	Members of my household becoming infected by COVID-19 Slightly concerned	Members of my household becoming infected by COVID-19 Somewhat concerned	Members of my household becoming infected by COVID-19 Very concerned	Members of my household becoming infected by COVID-19 N/A
Having enough food during the pandemic	Having enough food during the pandemic Not at all concerned	Having enough food during the pandemic Slightly concerned	Having enough food during the pandemic Somewhat concerned	Having enough food during the pandemic Very concerned	Having enough food during the pandemic N/A
Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.)	Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) Not at all concerned	Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) Slightly concerned	Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) Somewhat concerned	Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) Very concerned	Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) N/A
Helping my children with online schooling	Helping my children with online schooling Not at all concerned	Helping my children with online schooling Slightly concerned	Helping my children with online schooling Somewhat concerned	Helping my children with online schooling Very concerned	Helping my children with online schooling N/A
Child care	Child care Not at all concerned	Child care Slightly concerned	Child care Somewhat concerned	Child care Very concerned	Child care N/A
Economic impact on my household	Economic impact on my household Not at all concerned	Economic impact on my household Slightly concerned	Economic impact on my household Somewhat concerned	Economic impact on my household Very concerned	Economic impact on my household N/A
Access to medical services (e.g., emergency care, basic medical care and needed prescriptions)	Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) Not at all concerned	Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) Slightly concerned	Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) Somewhat concerned	Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) Very concerned	Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) N/A
The emotional health of my household	The emotional health of my household Not at all concerned	The emotional health of my household Slightly concerned	The emotional health of my household Somewhat concerned	The emotional health of my household Very concerned	The emotional health of my household N/A
The safety of my community during the pandemic	The safety of my community during the pandemic Not at all concerned	The safety of my community during the pandemic Slightly concerned	The safety of my community during the pandemic Somewhat concerned	The safety of my community during the pandemic Very concerned	The safety of my community during the pandemic N/A
Ability to pay my rent or mortgage	Ability to pay my rent or mortgage Not at all concerned	Ability to pay my rent or mortgage Slightly concerned	Ability to pay my rent or mortgage Somewhat concerned	Ability to pay my rent or mortgage Very concerned	Ability to pay my rent or mortgage N/A

Not at all concerned

Slightly concerned

Somewhat concerned

Very concerned

N/A

Members of my household becoming infected by COVID-19

Members of my household becoming infected by COVID-19 Not at all concerned

Members of my household becoming infected by COVID-19 Slightly concerned

Members of my household becoming infected by COVID-19 Somewhat concerned

Members of my household becoming infected by COVID-19 Very concerned

Members of my household becoming infected by COVID-19 N/A

Having enough food during the pandemic

Having enough food during the pandemic Not at all concerned

Having enough food during the pandemic Slightly concerned

Having enough food during the pandemic Somewhat concerned

Having enough food during the pandemic Very concerned

Having enough food during the pandemic N/A

Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.)

Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) Not at all concerned

Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) Slightly concerned

Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) Somewhat concerned

Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) Very concerned

Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc.) N/A

Helping my children with online schooling

Helping my children with online schooling Not at all concerned

Helping my children with online schooling Slightly concerned

Helping my children with online schooling Somewhat concerned

Helping my children with online schooling Very concerned

Helping my children with online schooling N/A

Child care

Child care Not at all concerned

Child care Slightly concerned

Child care Somewhat concerned

Child care Very concerned

Child care N/A

Economic impact on my household

Economic impact on my household Not at all concerned

Economic impact on my household Slightly concerned

Economic impact on my household Somewhat concerned

Economic impact on my household Very concerned

Economic impact on my household N/A

Access to medical services (e.g., emergency care, basic medical care and needed prescriptions)

Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) Not at all concerned

Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) Slightly concerned

Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) Somewhat concerned

Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) Very concerned

Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) N/A

The emotional health of my household

The emotional health of my household Not at all concerned

The emotional health of my household Slightly concerned

The emotional health of my household Somewhat concerned

The emotional health of my household Very concerned

The emotional health of my household N/A

The safety of my community during the pandemic

The safety of my community during the pandemic Not at all concerned

The safety of my community during the pandemic Slightly concerned

The safety of my community during the pandemic Somewhat concerned

The safety of my community during the pandemic Very concerned

The safety of my community during the pandemic N/A

Ability to pay my rent or mortgage

Ability to pay my rent or mortgage Not at all concerned

Ability to pay my rent or mortgage Slightly concerned

Ability to pay my rent or mortgage Somewhat concerned

Ability to pay my rent or mortgage Very concerned

Ability to pay my rent or mortgage N/A

Question Title

* 3. If important information about COVID-19 and our community needs to be shared, which of the following do you rely on for updates?

Local television stations

Local radio stations

Local newspapers and news websites

Local government websites

Schools

Social Media (please specify below: Facebook, Nextdoor, Twitter, Instagram)

Other organizations (please specify below: churches, clubs, nonprofits, etc.)

Local government e-newsletters or text message notifications

Other or specify from response above

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* 4. Is there anything else you would like to share with us?

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* 5. What is Your Age range?

18 to 24 years old

25 to 44 years old

45 to 64 years old

65 years or older

Prefer Not to Answer

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* 6. How would you describe your gender?

Female (including transgender women)

Male (including transgender men)

Prefer Not to Answer

Prefer to Self Describe as:

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* 7. What is Your Race?

White

Black or African American

American Indian or Alaska Native

Asian

Prefer Not to Answer

Other Race:

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* 8. Are you of Hispanic, Latino, or Spanish origin?

No - Not of Hispanic, Latino, or Spanish origin

Yes - Mexican, Mexican Am. or Chicano

Yes - Puerto Rican

Yes - Cuban

Yes - Another Hispanic, Latino or Spanish origin

Prefer Not to Answer

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* 9. What is your approximate average household income?

$0-$24,999

$25,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$124,999

$125,000-$149,999

$150,000-$174,999

$175,000-$199,999

$200,000 and up

Prefer Not to Answer

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* 10. Which Ward Do You Reside In?

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* 11. Your Contact Information (optional)

Name

ZIP/Postal Code

Email Address

Phone Number

Individual Needs Assessment

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* 1. In the local pandemic emergency, which services are most important to you? (check all that apply and add specific details in the comment box)

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* 2. How concerned are you with the following issues impacting your family/household in the coming months as a result of the COVID-19 pandemic?

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* 3. If important information about COVID-19 and our community needs to be shared, which of the following do you rely on for updates?

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* 4. Is there anything else you would like to share with us?

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* 5. What is Your Age range?

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* 6. How would you describe your gender?

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* 7. What is Your Race?

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* 8. Are you of Hispanic, Latino, or Spanish origin?

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* 9. What is your approximate average household income?

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* 10. Which Ward Do You Reside In?

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* 11. Your Contact Information (optional)