COVID-19 NEEDS ASSESSMENT

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* 1. Select county of residence.

Harrison

Jasper

Newton

Panola

Sabine

San Augustine

Shelby

Tyler

Upshur

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* 2. In the next 60 days, are you worried about your ability to find or purchase food for yourself or people in your household?

Yes

If no, please explain

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* 3. Do you need assistance with rent?

Yes

if yes, how much is your monthly rent?

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* 4. Do you need assistance with childcare?

Yes

If yes, what are the ages of the children

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* 5. Do you need assistance with transportation to work?

Yes

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* 6. Do you need help with basic need products?

Yes

If yes, specify the need(s)

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* 7. Do you need help with prescriptions?

Yes

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* 8. Do you need help with your utilities?

Yes

If yes, specify (water, electric, gas)

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* 9. Do you need assistance with paying mortgage?

Yes

If yes, how much is your monthly mortgage?

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* 10. Do you have the financial resources to pay for medical treatment if you or a family member were to become ill?

Yes

If no, please explain

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* 11. Are there any other needs that were not identified?

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* 12. Optional contact information assistance.

Name

Address

Address 2

City/Town

State/Province

Zip/Postal Code

Country

Phone

COVID-19 NEEDS ASSESSMENT

Question Title

* 1. Select county of res﻿idence.

Question Title

* 2. In the next 60 days, are you worried about your ability to find or purchase food for yourself or people in your household?

Question Title

* 3. Do you need assistance with rent?

Question Title

* 4. Do you need assistance with childcare?

Question Title

* 5. Do you need assistance with transportation to work?

Question Title

* 6. Do you need help with basic need products?

Question Title

* 7. Do you need help with prescriptions?

Question Title

* 8. Do you need help with your utilities?

Question Title

* 9. Do you need assistance with paying mortgage?

Question Title

* 10. Do you ﻿have the financial resources to pay for medical treatment if you or a family member were to become ill?

Question Title

* 11. Are there any other needs that were not identified?

Question Title

* 12. Optional contact information assistance.

* 1. Select county of residence.

* 10. Do you have the financial resources to pay for medical treatment if you or a family member were to become ill?