Operation Threshold COVID-19 Related Needs Survey

Operation Threshold COVID-19 Needs Survey

Please help Operation Threshold identify and respond to the needs in the Cedar Valley as a result of COVID-19 by filling out this survey. All responses are anonymous. To apply for assistance or to speak with someone at Operation Threshold, you may email us at Crisis@operationthreshold.org or call (319)291-2065. Thank you for helping us help our community!!

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* 1. What county do you live in?

Black Hawk

Buchanan

Grundy

Other (please specify)

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* 2. My current stress level is:

	Low		Average		High
Regarding finances	Regarding finances Low	Regarding finances	Regarding finances Average	Regarding finances	Regarding finances High
Regarding employment	Regarding employment Low	Regarding employment	Regarding employment Average	Regarding employment	Regarding employment High
Regarding health	Regarding health Low	Regarding health	Regarding health Average	Regarding health	Regarding health High
Regarding family	Regarding family Low	Regarding family	Regarding family Average	Regarding family	Regarding family High
Regarding community	Regarding community Low	Regarding community	Regarding community Average	Regarding community	Regarding community High
Regarding the future	Regarding the future Low	Regarding the future	Regarding the future Average	Regarding the future	Regarding the future High
Overall	Overall Low	Overall	Overall Average	Overall	Overall High

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* 3. Food Needs - please mark the answer that best describes the situation of your household

We only have enough food for the next 3 days or less

We have enough food for the next 4 - 7 days

We have enough food for the next 8 - 14 days

We have enough food for 15 days or more

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* 4. Do you need financial help to obtain food?

Yes

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* 5. Do you need someone to deliver food?

Yes

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* 6. Do you need financial help to pay your rent or mortgage?

Yes, I need help paying my rent

Yes, I need help paying my mortgage

No, I can make my rent or mortgage payment

If yes, starting with which month?

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* 7. Do you need help paying property taxes?

Yes

Not applicable

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* 8. Do you need help paying renter's or homeowner's insurance?

Yes

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* 9. Transportation Needs - please check all that apply:

We need financial help for gas

We need help paying for a bus pass or for Regional Transit

We need financial help to pay for car insurance

We need financial help to make a car payment

We need help paying our car registration

We need rides for medical needs (medical treatment, pick up prescriptions, etc.)

We need rides for errands such as getting to the bank, to apply for assistance, going to the post office, pay bills, pick up food from the food pantry, etc.

Other transportation needs (please specify)

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* 10. Do you need help with paying for your utilities? Please check all that apply:

Gas

Electric

Water

Sewer and Garbage

Internet

Phone

Propane or Fuel oil

Other (please specify)

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* 11. Other needs - please check all that apply:

Diapers

Formula

Baby wipes

Disinfecting wipes/cleaning products

Hand soap or hand sanitizer

Laundry soap

Toilet paper

Computer use for remote work or school

Child care

Mental health services

Help finding a job

Other (please specify)