As part of COVID-19 (Coronavirus) emergency-response efforts, several Pacific Island/COFA serving organizations are asking you to complete this survey to help us gather information on the current and ongoing needs of our community members and their families. The data/information collected will help us gain a better understanding of the needs of our community, in order to assist and help policymakers, agencies and partners address effective culturally responsive measures to meet the needs for our people. Your response is highly needed and greatly appreciated.

COFA partner organizations: Arkansas Coalition of Marshallese (ACOM), COFA Alliance National Network (CANN), COFA-Community Leadership & Advocacy Network, and We Are Oceania (WAO)

Note:
-One survey per family
-Asterisk (*) denotes required response

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* 1. Email Address:

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* 2. Phone #:

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* 3. What is your zip code?

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* 4. What COFA language(s) are spoken in your family? (Select all that apply)

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* 5. How many people are in your family?

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* 6. Please list the number of citizens in your family to the country listed:

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* 7. Is anyone in your family on active duty in the military?

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* 8. If yes, how many in your family are on active duty in the military?

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* 9. Are there more than one family in your home? 
Note: If yes – please fill out for your family only

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* 10. How many people in your family including yourself are 65 years or older?

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* 11. List the name of the church(es) you and/or your family attend?

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* 12. What industry best describes the occupation of those in your family?

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* 13. Since COVID-19 started, have you or anyone in your family had to leave to go to work?

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* 14. Has anyone in your family been laid off, suspended, or had to reduce hours as a result of COVID-19?

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* 15. In your family, check the number of health problems per each individual.

  Person 1 Person 2 Person 3 Person 4 Person 5
High blood pressure
Obesity
Diabetes
Weak immune system
Cancer
Diseases of the lungs
Diseases of the heart
Diseases of the kidneys
Diseases of the liver
No health problems
Other

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* 16. If you selected "Other" or need to describe health problems for additional family members, please explain below.

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* 17. Have you or anyone in your family tested positive for COVID-19? 
If yes, answer questions 18-22.

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* 18. If yes, how did you or they find out? (Skip if N/A)

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* 19. Were you or they showing any symptoms such as coughing, fever, tiredness, difficulty breathing?

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* 20. Have you or they recovered?

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* 21. Have you or they been quarantined?

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* 22. If yes, how have you or they been quarantined?

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* 23. If you know how COVID-19 was contracted, please explain.

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* 24. Has anyone in your family died from COVID-19?

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* 25. Are you and your family following COVID-19 personal health guidelines such as? If no, please explain in Question 25.

  Yes No
Staying at least 6 feet apart
Wearing masks
Frequent hand washing
Other

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* 26. If no, please explain. 

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* 27. Do you have access to personal protection equipment (masks, gloves)?

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* 28. What help (resources or services) do you or anyone in your family need right now because of COVID-19? (check all that apply)

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* 29. List 3 biggest problems or worries you and your family are having or facing because of COVID-19? (Write N/A if no problems or worries.)

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* 30. Do you have a primary care doctor?

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* 31. Have you or anyone in your family had any negative interactions with any of the below within the last year? (Check all that apply)

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* 32. Has the recent travel restrictions to the FSM/RMI/Palau negatively impacted you or anyone in your family?

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* 33. Is anyone in your family registered to vote in the US?

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* 34. If yes, how many?

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* 35. Does anyone in your family vote in your home country?

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* 36. If yes, please list the number next to country.

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* 37. Have you or your family completed the census?

This survey was supported by the following organizations: CANN-Washington, Micronesian Coalition, CANN-Texas, CANN-Arizona, RMI Consulate Offices – Arkansas and Hawaii, and FSM Consulate Offices – Oregon and Hawaii

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