East Providence Health Equity Zone (HEZ) Immediate Needs Survey

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* 1. Has the virus outbreak affected your ability to pay rent or mortgage?

No, I can pay rent or mortgage

Yes, I can’t pay

Yes, I’m worried about next month

Yes, I’ve been evicted

I don’t pay rent or mortgage

I do not know where I will sleep tonight

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* 2. Are you struggling or unable to pay for? Please circle all that apply.

Utilities

Transportation (vehicle or bus)

Laundromat

Personal hygiene items

Childcare items (diapers, wipes, etc.)

Childcare/babysitting

School supplies

Medication

Face Masks and PPE

Other (please specify)

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* 3. Do you own a car or have access to one?

Yes, I own or have access to a car

No, I do not own or have access to a car

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* 4. Has the virus outbreak affected your current employment status?

No, it has not affected my employment status

Yes, I’m working fewer hours

Yes, I’m temporarily laid off

Yes, I’m permanently laid off

Other (please specify)

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* 5. Can you feed yourself and your family?

Yes, I can feed my family at the same level

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* 6. Are you able to access medical care?

Yes, I have access to medical care

No, I don’t have access to medical care

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* 7. Is there someone else you are worried about?

Yes, I am worried about a family member, friend, and/or neighbor. I would like you to contact me about helping them.

No, I am not worried about anyone

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* 8. Do you have access to access to the Internet?

Yes

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* 9. Do you feel safe in your home?

Yes

No, I would you like someone to contact you about getting help

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* 10. Are you in quarantine due to illness or caring for someone with an illness?

Yes

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* 11. I would like to stay up to date on HEZ news and updates

Name

Company

City/Town

Email Address