Skip to content
HPI Survey
1.
What is your age group?
18-24
25-34
35-44
45-54
55-64
65+
2.
How many people currently live in your household?
3.
How many people in your household are under the age of 18?
4.
How do you receive news and information?
Local News Station
National News Station
Local Government
Facebook/Social Media
The Internet
From family and friends
Other (please specify)
5.
How have you or a member of your household been impacted by the most recent events?
Loss of employment
Reduced hours or pay
Loss of childcare
Caring for loved one
Health/Illness
I have not been impacted
Other (please specify)
6.
Do you work in any of the following industries?
Restaurant/Food Services
Daycare
Government
Customer Service
Self Employed
Healthcare
I am not employed
Other (please specify)
7.
In your current situation, what type of assistance would be
most
beneficial to you and your household?
Groceries/ Household Supplies
Utilities
Rental Assistance
I don't need assistance at this time
Other (please specify)
8.
If you are eligible for any stimulus proceeds from the government, how would you apply it?
Put in savings
Rent/mortgage
Groceries/Household Supplies
Pay off a past due debt
Other (please specify)
9.
We are in this together, what else do we need to know?
10.
To better assist you, please provide your contact information.
Name
Place of Employment
Home Address
Apartment #
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
Current Progress,
0 of 10 answered