2022 VOICES Membership Needs Assessment Survey

As we plan for the months ahead, we are conducting this brief survey to assess the needs of our community. Your responses are confidential and will help guide the development of our support services and programs. The survey will take approximately five minutes to complete.

Please reply by Thursday, March 31.

*1.First Name(Required.)

*2.Last Name(Required.)

*3.Contact Information(Required.)

Preferred Email address

Preferred Phone number

Phone type: Cell, Home, Work, etc.

Secondary Phone

4.Home Address

Address

Address 2

City

State

ZIP/Postal Code

Country other than U.S.

*5.Age(Required.)

18-30

31-40

41-50

51-60

61-70

71-80

81 +

Prefer not to answer

*6.Gender(Required.)

Male

Female

Non-binary

Prefer not to answer

*7.How do you identify your race? ** Check all that apply(Required.)

Caucasian

Black or African American

Hispanic

Asian

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Prefer not to answer

*8.Have you been impacted by a traumatic event?(Required.)

Yes

9.If yes, which event? (Check all that Apply)

9/11

COVID-19

Other (please specify)

*10.How do you identify yourself? *Select all that apply(Required.)

Family Member of a Victim

Family Member of someone whose died due to a 9/11 related illness

Family Member of someone with a 9/11 related illness

Survivor

Responder

Mental Health Provider

Law Enforcement

Government Agency Employee

Emergency Management Personnel

General Public

Other (please specify)

Please note: If you've lost a loved one, please complete questions 11, 12 and 13. Otherwise proceed to question #14

11.Name of Victim

12.Relationship to Victim

Other (please specify)

13.Specify Location

Other (please specify)

*14.Have you lost a loved one in the past 3 years?(Required.)

Yes

15.If yes, how?

Other (please specify)

25%

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