COFA COVID-19 Family Needs Assessment

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.

Note:

-One survey per family

-Asterisk (*) denotes required response

Question Title

* 1. Email Address:

Question Title

* 2. Phone #:

Question Title

* 3. What is your zip code?

Question Title

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

Chuukese

Kosraen

Pohnpeian

Yapese

Marshallese

Palauan

Question Title

* 5. How many people are in your family?

Question Title

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

Chuuk

Kosrae

Pohnpei

Yap

Total FSM:

RMI

Palau

United States

Other:

Question Title

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

Yes

Question Title

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

Question Title

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

Yes

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Question Title

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

Question Title

* 17. Have you or anyone in your family been tested for COVID-19?

Yes

Question Title

* 18. Have you or anyone in your family tested positive for COVID-19?
If yes, answer questions 19-25.

Yes

Question Title

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

Question Title

* 20. Have you or anyone in your family been hospitalized for COVID-19?

Yes

Question Title

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

Yes

N/A

Question Title

* 22. Have you or they recovered?

Yes

N/A

Question Title

* 23. Have you or they been quarantined?

Yes

N/A

Question Title

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

Question Title

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

Question Title

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

Yes

Question Title

* 27. Are you and your family following COVID-19 personal health guidelines such as? If no, please explain in Question 26.

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

Question Title

* 28. If no, please explain.

Question Title

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

Yes

Question Title

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

Official information in my primary language

Food

Personal protection equipment like masks, gloves, etc.

Housing (Payment for rent/mortgage or protection from eviction)

Unemployment

Utilities

Broadband / Internet

Transportation

Interpretation services in language for talking to the doctor or other officials

Healthcare

Mental healthcare

Social services (Support with official paperwork like notary, passport, etc.)

Insurance coverage (Medicaid, State-based or other insurance coverage)

Immigration and other legal concerns

School (help with assignments) or childcare for children

Elder-care

Financial assistance to pay loans or credit cards

Small business support

Financial assistance to help with COVID-19 related expenses (isolation, quarantine, funeral, etc.)

N/A

Other (please specify)

Question Title

* 31. 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.)

Question Title

* 32. Do you have a primary care doctor?

Yes

Question Title

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

Law enforcement

Health services

Schools

Housing

Unemployment

Social services

N/A

Question Title

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

Yes

Question Title

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

Yes

Question Title

* 36. If yes, how many?

Question Title

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

Yes

Question Title

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

FSM

RMI

Palau

Question Title

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

Yes

COFA COVID-19 Family Needs Assessment

Question Title

* 1. Email Address:

Question Title

* 2. Phone #:

Question Title

* 3. What is your zip code?

Question Title

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

Question Title

* 5. How many people are in your family?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 17. Have you or anyone in your family been tested for COVID-19?

Question Title

* 18. Have you or anyone in your family tested positive for COVID-19? If yes, answer questions 19-25.

Question Title

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

Question Title

* 20. Have you or anyone in your family been hospitalized for COVID-19?

Question Title

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

Question Title

* 22. Have you or they recovered?

Question Title

* 23. Have you or they been quarantined?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 27. Are you and your family following COVID-19 personal health guidelines such as? If no, please explain in Question 26.

Question Title

* 28. If no, please explain.

Question Title

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

Question Title

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

Question Title

* 31. 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.)

Question Title

* 32. Do you have a primary care doctor?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 36. If yes, how many?

Question Title

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

Question Title

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

Question Title

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

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

* 18. Have you or anyone in your family tested positive for COVID-19?
If yes, answer questions 19-25.