HPI Survey

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* 1. What is your age group?

18-24

25-34

35-44

45-54

55-64

65+

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* 2. How many people currently live in your household?

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* 3. How many people in your household are under the age of 18?

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* 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)

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* 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)

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* 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)

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* 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)

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* 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)

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* 9. We are in this together, what else do we need to know?

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* 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