COVID Impact Family/Individual Support Questionaire

Help us understand how best to help people in need.

There are numerous local non-profit organizations collaborating to provide support to Southcoast Communities. We are asking you to share your opinion on how to best reach people with what they need. Please complete the questionnaire below from your perspective. The survey is anonymous and will help us better understand how to help people in need of basic services such as food, shelter or emotional support. Please be as candid as possible. The survey is anonymous, but you will have the option at the end of the survey to sign up for notifications.

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* 1. Please select one

I am a client

I work for an Agency. Worker name and Agency Name

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* 2. Have you ever received emergency support before?

Yes

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* 3. Do you or your family currently need any of the following supports? Check all that apply.

Groceries

Hot Meals

Cleaning Supplies

Personal Hygiene Products

Shelter

Rental Assistance

Emotional Support / Counseling

Other (please specify)

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* 4. If you were to get help please rate how likely you are to participate in the following approaches.

	Very Likely	Somewhat Likely	Not Likely
Be provided with a gift card to a grocery store	Be provided with a gift card to a grocery store Very Likely	Be provided with a gift card to a grocery store Somewhat Likely	Be provided with a gift card to a grocery store Not Likely
Pick up groceries in neighborhood at a community drop	Pick up groceries in neighborhood at a community drop Very Likely	Pick up groceries in neighborhood at a community drop Somewhat Likely	Pick up groceries in neighborhood at a community drop Not Likely
Groceries delivered to your door step	Groceries delivered to your door step Very Likely	Groceries delivered to your door step Somewhat Likely	Groceries delivered to your door step Not Likely
Congregate meal sites Grab and Go	Congregate meal sites Grab and Go Very Likely	Congregate meal sites Grab and Go Somewhat Likely	Congregate meal sites Grab and Go Not Likely
Pick up food at a local restaurant	Pick up food at a local restaurant Very Likely	Pick up food at a local restaurant Somewhat Likely	Pick up food at a local restaurant Not Likely

Other (please specify)

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* 5. How have you financially been impacted by the Covid-19 crisis?

No Change in Income

Reduced Income

Lost Income

Other (please specify)

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* 6. What can the community do to assist you?

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* 7. Can you get to a distribution site to pick up?

Yes

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* 8. Would you like to receive groceries delivered to your home? If you click yes, you MUST fill out contact information. We collect this so that we can contact you to arrange delivery. The information is not shared with any outside government agency.

Yes