Thank you for completing this survey! The information you provide here will help us better understand your current needs in relation to the COVID-19 pandemic. The information you provide will remain anonymous, and your participation is completely voluntary. Your responses will not impact services received from Teen Health Connection or any other community providers.

Question Title

* 1. Your age:

Question Title

* 2. Your gender:

Question Title

* 3. Your race/ethnicity: (Select all that apply.)

Question Title

* 4. Your marital status:

Question Title

* 5. Your zip code:

Question Title

* 6. How old are your children?

Question Title

* 7. How much have the following areas been impacted or disrupted for you and your household due to COVID-19?

  No impact/No change to daily behavior Some impact/Does not significantly change daily behavior Noticeable impact/Planning for reduced access Significant daily disruption/Experiencing reduced access Severe daily disruption/Immediate household need N/A
Food Access
Employment
Transportation
Child Care
Education/schooling
Housing
Utilities
Household supplies
Critical health care/sick care
Preventative health care
Mental health care
Clothing
Household income
Neighborhood safety

Question Title

* 8. What have been the biggest challenges or hardships you have personally experienced due to COVID-19?

Question Title

* 9. What have been the biggest challenges or hardships your teen(s) have experienced due to COVID-19?

Question Title

* 10. What have been the biggest challenges or hardships other members of your family experienced due to COVID-19?

Question Title

* 11. What have been the biggest challenges or hardships your neighborhood or community experienced due to COVID-19?

Question Title

* 12. Is there anything else that you need that you are unable to get/find, or that you wish you had during this time?

Question Title

* 13. Where have you gotten support during COVID-19?

Question Title

* 14. What information or topics would be most helpful for you to learn more about at this time?  

Question Title

* 15. Please share your thoughts about resources and solutions that would help you and your community get through COVID-19.

T