COVID19 Community Needs Check In

Thank you for taking the time to fill out our survey!

Dear community members, we are reaching out to you during the COVID-19 pandemic to gain an idea of the most urgent community needs. Please respond to the questions below. Any personal information shared will be confidential.

If you would like someone from NROCRC to follow-up with you, please call 613-596-5626 or email magordon@nrocrc.org.

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* 1. Please indicate your postal code in the list below; this will help us identify where in our catchment that specific need exist.

K2G

K2J

K2H

K4M

K4P

K0A

Other (please specify)

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* 2. Please share your age. This will help us determine the right service for you.

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* 3. What are your current main concerns related to COVID-19? Check all that apply.

Not able to afford food

Not being able to leave the home for essential trips

No transportation to pick up food or medicine

Loss of employment due to COVID-19

Not knowing where to go for help

Not able to pay rent/mortgage/bills

Having children at home/ online schooling

Stress/anxiety about the COVID-19 virus

Keeping your family healthy

Not having anyone to talk with

Lack of mental wellness support for vulnerable people (seniors, immunocompromised, etc)

Other (please specify)

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* 4. How many family friends or relatives do you have who can support you in times of need? (eg. Pick up groceries or medicine for you, accompany you to a doctor's appointment if you are unwell, look after children, etc)

# of relatives/family members

# of close friends

# other support people

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* 5. Do you have access to a telephone at home?

Yes

Other (please specify)

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* 6. Do you have access to a computer with internet access (wifi) at home?

Yes

Other (please specify)

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* 7. Do you have access to a device with internet connectivity?

Yes

Other (please specify)

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* 8. Do you receive financial support from the government as your family's main source of income (eg. Welfare, Ontario Works, ODSP, OSAP, CCB etc)?

Yes

Other (please specify)

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* 9. Has your household's employment status been affected by COVID19? Check all that apply.

My household's employment has not been affected by COVID-19

Job loss

Reduction in hours

I was not employed prior to COVID19

I was a student prior to COVID19

Other (option to type in)

Other (please specify)

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* 10. Are you eligible to recieved Canada's Emergency Response Benefit (CERB)?

Not eligible

Eligible, but have not applied

Eligible and have applied or have received payment

Perfer not to answer

Other (please specify)

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* 11. Thinking about the next 3 - 6 months, what are your concerns?

Ability to afford food

Transportation

Ability to afford medications

Ability to go out for essential trips

Loss of employment

Loneliness

Childcare and/or children not able to keep up with schoolwork

Ability to pay rent/mortgage/bills

Increased stress due to COVID-19 and its implications

Lack of ability to secure summer employment

Lack of opportunities for children and/or youth

Other (please specify)

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* 12. If you would like us to follow up with you or a wellness call, please share your phone number or email address.

First Name

Email Address

Phone Number