Rico Coronavirus Emergency Needs Assessment

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* 1. Household situation (check all that apply):

I live alone

I live with a partner or roommates

I live with children 0 - 4 years old

I live with children 5 - 8 years old

I live with children 9 - 12 years old

I live with children 13 - 15 years old

I live with children 16 - 18 years old

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* 2. How vulnerable are you to the coronavirus

I am under 65 and have no underlying health issues.

I am 65+ but I have no underlying health issues.

I have underlying health issues that may make me more vulnerable to the coronavirus.

Someone in my household has underlying health issues that may make them more vulnerable to the coronavirus.

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* 3. How has the coronavirus affected your job status?

My employment is secure - no reduced hours, no anticipated layoff or pay reduction.

I have been temporarily laid off but will be returning to work with no loss of pay.

My hours have been reduced and I am anticipating a pay reduction.

I have been laid off with no return date.

I am not sure what is going to happen with my job situation.

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* 4. If your hours have been reduced or if you lost your job for the foreseeable future, how financially stable are you?

Fine. I have resources

Fine for 1 - 2 months but then I will need help.

I anticipate needing help in less than a month.

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* 5. I will need help with (check all that apply):

Food

Rent

Utilities

Transportation/gas money

Daily welfare check

I will not need help in the foreseeable future

Internet hot spot for on-line education and services

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* 6. I may need help with rent and utilities:

My combined expenses are $1000 or less per month.

My combined expenses are $1001 - $1500 per month.

My combined expenses are $1501 - $2500 per month.

My combined expenses are $2501 - $3500 per month.

My combined expenses are $3500 plus per month.

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* 7. I (or members of my family) may need help with food or delivery services.

Breakfast

Lunch

Dinner

Deliveries of groceries

Deliveries of prescriptions

A ride(s) to a medical appointment

A ride(s) to work

I will not need help in the foreseeable future

Other (please specify)

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* 8. If this situation becomes long term, six weeks plus, I will need help with (check all that apply):

Daycare

Supervised outdoor activities for young children

Supervised outdoor activities for older children

I do not have children

I have children but do not anticipate needing child related help

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* 9. Will you need a daily phone call from a volunteer to make sure that you are well and don't need anything?

Yes

My number is:

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* 10. Are you interested in volunteering or do you have any other comments/concerns (please use comment box)?

Yes

My number/email address is: