NHPIs COVID-19 Household Survey

As part of COVID-19 (Coronavirus) emergency-response efforts, the National Pacific Islander COVID-19 Response Team and partner organizations are asking you to complete this survey to help us gather information on the current and ongoing needs of our community members and their families.

The data/information collected will help us gain a better understanding of the needs of our community, in order to assist and help policymakers, agencies and partners address effective culturally responsive measures to meet the needs for our people. Your response is highly needed and greatly appreciated.

Question Title

* 1. What is your zip code?

Question Title

* 2. What is your household’s ethnic group? (check all that apply)

Polynesian: Native Hawaiian

Polynesian: Samoan

Polynesian: Tongan

Polynesian: Tahitian

Polynesian: Tokelauan

Micronesian: Chamorro

Micronesian: Marshallese

Micronesian: Chuukese

Micronesian: Pohnpeian

Micronesian: Yapese

Micronesian: Kosraen

Micronesian: Palauan

Micronesian: Carolinian

Micronesian: I-Kiribati

Melanesian: Fijian

Melanesian: Papua New Guinean

Melanesian: Solomon Islander

Melanesian: Ni-Vanuatu

Other Polynesian, Micronesian or Melanesian

Question Title

* 3. How many people are in your household (living in your house)?

Question Title

* 4. Number of family members in each age group

0 to 4 years

5 to 12 years

13 to 17 years

18 to 24 years

25 to 34 years

35 to 44 years

45 to 54 years

55 to 64 years

65 years or older

Question Title

* 5. Do you have at least one adult in your household that speaks English?

Yes (go to question 6)

No (go to question 7)

Question Title

* 6. How well do they speak English?

Very well

Well

Not well

I don't know

Question Title

* 7. For information on health and other services, what language(s) do you prefer? (check all that apply)

Samoan

Chamorro

Tongan

Marshallese

Chuukese

Pohnpeian

Palauan

Kosraean

Yapese

Fijian

English

Other Polynesian, Micronesian or Melanesian

Question Title

* 8. Is anyone in your household on active duty in the military?

Yes

Question Title

* 9. Is anyone in your household a US veteran?

Yes

Question Title

* 10. Do you attend church?

Yes

Question Title

* 11. Please list the number of people in your household that work in any of these essential occupations. (If no one is working in these occupations, enter "0")

Healthcare or health services (e.g., doctor, medical assistant, home healthcare)

First responder and law enforcement (e.g., police, emergency medical technician, fire fighter)

Food preparation or service (e.g., chef, wait staff)

Sales (e.g., grocery store, gas station, drug store)

Maintenance (e.g., utilities, automotive)

Janitorial/cleaning services

Construction (including plumbing and electrical worker)

Food production or processing (e.g., agriculture, meat processing)

Transit/transportation worker (e.g., bus driver, airport worker)

Teacher, instructor or childcare provider

Protective Services (e.g., security guard)

Community and social services

Question Title

* 12. Since COVID-19 started, have you or has anyone in your household had to leave your house to go to work?

Yes

Question Title

* 13. Did you or members of your household receive Personal Protective Equipment (mask, gloves, etc.) from your employer to prevent the spread of COVID-19?

Yes

I don't know

Question Title

* 14. Has anyone in your household been furloughed, laid off, or had to reduce hours as a result of COVID-19?

Yes

Question Title

* 15. Do you or members of your household have a primary care doctor?

Yes (go to question 16)

No (go to question 17)

Question Title

* 16. Including yourself, how many members of your household have a primary care doctor?

Question Title

* 17. In your family, check the number of health problems per each individual.
If you have more than FIVE people in your household please choose the top five with the most health problems.

	Person 1	Person 2	Person 3	Person 4	Person 5
High blood pressure	High blood pressure Person 1	High blood pressure Person 2	High blood pressure Person 3	High blood pressure Person 4	High blood pressure Person 5
Obesity	Obesity Person 1	Obesity Person 2	Obesity Person 3	Obesity Person 4	Obesity Person 5
Diabetes	Diabetes Person 1	Diabetes Person 2	Diabetes Person 3	Diabetes Person 4	Diabetes Person 5
Weak immune system	Weak immune system Person 1	Weak immune system Person 2	Weak immune system Person 3	Weak immune system Person 4	Weak immune system Person 5
Cancer	Cancer Person 1	Cancer Person 2	Cancer Person 3	Cancer Person 4	Cancer Person 5
Diseases of the lungs (not asthma)	Diseases of the lungs (not asthma) Person 1	Diseases of the lungs (not asthma) Person 2	Diseases of the lungs (not asthma) Person 3	Diseases of the lungs (not asthma) Person 4	Diseases of the lungs (not asthma) Person 5
Asthma	Asthma Person 1	Asthma Person 2	Asthma Person 3	Asthma Person 4	Asthma Person 5
Diseases of the heart	Diseases of the heart Person 1	Diseases of the heart Person 2	Diseases of the heart Person 3	Diseases of the heart Person 4	Diseases of the heart Person 5
Diseases of the kidneys	Diseases of the kidneys Person 1	Diseases of the kidneys Person 2	Diseases of the kidneys Person 3	Diseases of the kidneys Person 4	Diseases of the kidneys Person 5
Diseases of the liver	Diseases of the liver Person 1	Diseases of the liver Person 2	Diseases of the liver Person 3	Diseases of the liver Person 4	Diseases of the liver Person 5
No health problems	No health problems Person 1	No health problems Person 2	No health problems Person 3	No health problems Person 4	No health problems Person 5
Other (please describe below)	Other (please describe below) Person 1	Other (please describe below) Person 2	Other (please describe below) Person 3	Other (please describe below) Person 4	Other (please describe below) Person 5

Other, please describe

Question Title

* 18. Have you or has anyone in your household tested positive for COVID-19?

Yes

33% of survey complete.

NHPIs COVID-19 Household Survey

Question Title

* 1. What is your zip code?

Question Title

* 2. What is your household’s ethnic group? (check all that apply)

Question Title

* 3. How many people are in your household (living in your house)?

Question Title

* 4. Number of family members in each age group

Question Title

* 5. Do you have at least one adult in your household that speaks English?

Question Title

* 6. How well do they speak English?

Question Title

* 7. For information on health and other services, what language(s) do you prefer? (check all that apply)

Question Title

* 8. Is anyone in your household on active duty in the military?

Question Title

* 9. Is anyone in your household a US veteran?

Question Title

* 10. Do you attend church?

Question Title

* 11. Please list the number of people in your household that work in any of these essential occupations. (If no one is working in these occupations, enter "0")

Question Title

* 12. Since COVID-19 started, have you or has anyone in your household had to leave your house to go to work?

Question Title

* 13. Did you or members of your household receive Personal Protective Equipment﻿ (mask, gloves, etc.) from your employer to prevent the spread of COVID-19?

Question Title

* 14. Has anyone in your household been furloughed, laid off, or had to reduce hours as a result of COVID-19?

Question Title

* 15. Do you or members of your household have a primary care doctor?

Question Title

* 16. Including yourself, how many members of your household have a primary care doctor?

Question Title

* 17. In your family, check the number of health problems per each individual.If you have more than FIVE people in your household please choose the top five with the most health problems.

Question Title

* 18. Have you or has anyone in your household tested positive for COVID-19?

* 13. Did you or members of your household receive Personal Protective Equipment (mask, gloves, etc.) from your employer to prevent the spread of COVID-19?

* 17. In your family, check the number of health problems per each individual.
If you have more than FIVE people in your household please choose the top five with the most health problems.