Puerto Rican Crisis

The Puerto Rican Crisis Impact

Please share your personal experience. All testimonials are confidential without express written consent.

* 1. What is your first name?

* 2. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

* 3. What is your gender?

Female

Male

Other

* 4. In what language do you speak most often?

Arabic

Armenian

Chinese

English

French

French Creole

German

Greek

Gujarati

Hindi

Italian

Japanese

Korean

Persian

Polish

Portuguese

Russian

Spanish

Tagalog

Urdu

Vietnamese

* 5. Hometown in Puerto Rico

* 6. What city do you currently live in?

* 7. Email

* 8. Phone

* 9. Referring Organization

* 10. Coordinating Staff Person

* 11. Do you agree to being publicly identified in the media/social media?

Yes

No

* 12. How have you or your family been impacted by the debt crisis and economic decline in Puerto Rico (layoff, pension taxed, lack of doctors, energy costs, moved to the mainland, housing problem, other)? Please include key dates, specific financial impact, compelling human interest stories.)