East Providence Health Equity Zone (HEZ) Immediate Needs Survey Question Title * 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 OK Question Title * 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) OK Question Title * 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 OK Question Title * 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) OK Question Title * 5. Can you feed yourself and your family? Yes, I can feed my family at the same level No OK Question Title * 6. Are you able to access medical care? Yes, I have access to medical care No, I don’t have access to medical care OK Question Title * 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 OK Question Title * 8. Do you have access to access to the Internet? Yes No OK Question Title * 9. Do you feel safe in your home? Yes No, I would you like someone to contact you about getting help OK Question Title * 10. Are you in quarantine due to illness or caring for someone with an illness? Yes No OK Question Title * 11. I would like to stay up to date on HEZ news and updates Name Company City/Town Email Address OK DONE