PerkUp CAFE Final Survey

Please complete the short survey below to be eligible for future grants in 2021. If you have any problems or questions while completing this survey, please call us at (844) 737-5871.

**This survey must be completed by January 31st in order to be eligible for the PerkUp program in 2021.

Question Title

* 1. Please verify your personal information

First and Last Name:

Email address:

Phone Number:

Gender (male, female, other):

Employment Status (active, furloughed, unemployed):

Current Employer (or none)

Total number of people living in your household:

Number of dependents (claimed on tax return):

Question Title

* 2. What is your race? (select all that apply)

White or Caucasian

Black or African American

Asian or Asian American

Native Hawaiian or Pacific Islander

American Indian or Alaskan Native

I choose not to specify

Other (please specify)

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* 3. Are you of Hispanic or Latino origin (ethnically)?

Yes

I choose not to respond

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* 4. What is your marital status?

Single, never married

Married or domestic partnership

Widowed

Divorced

Separated

I choose not to respond

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* 5. Filing status on most recent tax return?

Single

Head of Household

Married filing jointly

Married filing separately

Qualifying widow(er)

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* 6. Since you took the last survey, how has your employment situation changed?

No change

More work hours

Started a new job

Less work hours

Lost a job or was furloughed

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* 7. Since you took the last survey, has the employment situation changed for any other adult living in your home, such as a spouse or partner?

Yes

Not applicable – I am the only adult in the home