Operation Threshold COVID-19 Related Needs Survey

1.What county do you live in?

Black Hawk

Buchanan

Grundy

Other (please specify)

2.My current stress level is:

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

4.Do you need financial help to obtain food?

Yes

No

5.Do you need someone to deliver food?

Yes

No

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?

7.Do you need help paying property taxes?

Yes

No

Not applicable

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

Yes

No

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)

Operation Threshold COVID-19 Related Needs Survey

Operation Threshold COVID-19 Needs Survey