* 2. How old are you?

* 3. Are you male or female?

* 4. How do you refer to yourself?

* 5. What type of housing do you live in?

* 6. How many people live in your household, including yourself?

* 7. What is your approximate average household income?

* 9. Were you personally affected by Superstorm Sandy?

* 10. How were you affected by Hurricane Sandy?
(mark all that apply)

* 12. Did you have any loss of income due to the storm?

* 13. Do you receive any type of home based care service such as a visiting nurse or meal delivery that was affected as a result of Superstorm Sandy?

* 14. Are you aware of the following types of resources? (Please mark all that apply)

* 15. Please check if you are still in need of the following resource(s) (check all that apply)

* 16. How did you find out the information regarding Hurricane Sandy recovery resources (e.g. Shelter, warming/charging stations and all the above listed in question 14 and 15)?

* 17. What is your preferred method of receiving general information about health and well-being resources?
(check all that apply)

* 18. Are you aware of the programs available regarding mold remediation by the municipal health departments?

* 19. How would you say your health in general was before Superstorm Sandy?

* 20. How would you say your health in general was after Superstorm Sandy?

* 21. How would you say your emotional health in general was before Superstorm Sandy?

* 22. How would you say your emotional health was in general after Superstorm Sandy?

* 23. As a result of Superstorm Sandy, what are the top five concerns with your health and overall well-being? (please check five)

* 24. do you have any illness or disability? [This can be a physical or mental illness lasting for more than 3 months. The signs may come and go or be present all the time.]

* 25. As a result of Superstorm Sandy, have you experienced any of the following:
(Please mark all that apply)

* 26. As a result of Superstorm Sandy, what types of services do you still need? (Please mark all that apply.)

* 27. What best describes how you are recovering from Superstorm Sandy?

* 28. Do you have any special conditions that are preventing you from recovering?

* 29. Would you like someone to reach out to you about the information that you have provided? Please provide your name, phone number, and email address.

* 30. Would you like to participate in a discussion about your experiences? Please provide your name phone number and email address.

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