COVID-19 Response - Stories Question Title * 1. Your Name Question Title * 2. Your Email Address Question Title * 3. Your Phone Number Question Title * 4. Are you a: person with a disability family member provider Other (please specify) Question Title * 5. Your story contains the following topics (check all that apply): health care home and community living employment transportation education safety connecting with others access to food Other (please specify) Question Title * 6. Share your story: Question Title * 7. Do you consent to us sharing your story? I DO consent to you sharing my story, using my name I DO consent to you sharing my story, but you cannot use my name I DO NOT consent to you sharing my story or using my name Question Title * 8. Do you have photos or videos to share along with your story? Yes No Question Title * 9. Have you contacted a local official or policymaker about your story? Yes No Question Title * 10. If you answered yes, to contacting a local official or policymaker about your story, please name the person you contacted and what their response was: Question Title * 11. If you believe additional action needs to be taken by your local official or legislator, what would that be? Question Title * 12. Other than becoming sick with COVID-19, what else might you be worried about? (check all that apply) Money Missing friends and family Access to food Access to medications Having staff to assist you Safety Mental health Housing Employment Other (please specify) Question Title * 13. Have you participated in the 'Coffee with Katheryne' sessions hosted by MODDC? Yes No Question Title * 14. (Optional) What is your race? White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Question Title * 15. (Optional) Do you live in an urban or rural area? Urban Rural (rural is defined as a community of less than 2,500 people) Question Title * 16. (Optional) What is your gender? Female Male Other (please specify) Done
