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* 1. Head of Household Last Name

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* 2. Head of Household First Name

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* 3. Race/Ethnicity?

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* 4. Which gender do you most closely identify with?

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* 5. Head of household contact phone number

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* 6. Head of household email address

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* 8. Number of people who reside in the home

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* 9. Ages of those in the home

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* 10. If there are children/youth, what grades are being served (check all that apply)

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* 11. Are the children dependent on formula or diapers?

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* 13. In the last 45 days, have you participated or attended any of the following (check all that apply)

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* 14. Are there any veterans in the home?

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* 15. Is there a pregnant woman in the household? If so, when is she due? Are there any maternal complications?

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* 16. Is anyone working outside of the home?

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* 17. Is anyone working in the home/teleworking?

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* 18. Do you currently work in a hospital, medical clinic, doctor’s office, nursing home or some other health-care facility? This includes part-time and unpaid work in a health care facility as well as professional nursing care provided in the home.

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* 19. Do you care for an elderly/high risk family member not living in the home?

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* 20. How do you obtain community information and updates (check all that apply)

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* 21. How do you heat your home?

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* 22. Do you have enough heat source to support your household needs for the next 30 days?

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* 23. Does anyone in the household have a chemical dependency (check all that apply)

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* 24. Do you have an emergency/safety plan in place?

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* 25. Do you have a home garden that can sustain you if necessary?

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* 26. Do you have a generator?

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* 27. Do you have basic toiletries and personal hygiene to last you 30 days (toilet paper)?

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* 28. Do you have a communication device in your home to call for help if needed?

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* 29. Do you have any animals? If so, what kind?

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* 31. Does your household receive commodities?

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* 32. Does your household receive WIC/SNAP?

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* 33. Do you have enough food to support your household needs for the next 30 days?

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* 34. Do you rely on tap water or bottled water? If bottled, how many days can you currently sustain your household?

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* 35. If you rely on tap water, do you have a filtration system?

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* 36. Do you have protein (hamburger, chicken, fish, etc) frozen to sustain your household?

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* 37. Is anyone currently ill in the household?

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* 38. Do you have a working humidifier or oxygen machine in the household?

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* 39. Do you have any medical devices that require distilled water?

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* 40. Does anyone have an underlying chronic medical condition (diabetes, asthma, etc.)?

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* 41. Does anyone have seasonal and/or food allergies?

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* 42. Does anyone in the home have a behavioral health or mental health need?

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* 43. Does someone in your household have a medical condition requiring access to medication?

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* 44. Does someone in your household have a prosthesis?

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* 45. Medical condition requiring access to equipment (example: dialysis, oxygen, etc.)?

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* 46. Do you have transportation needs for necessary medical appointments (cancer, dialysis, etc.)?

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* 47. Do you receive your treatment via Indian Health Council or another provider?

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* 48. Do you currently have Tylenol/Motrin or both on hand?

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* 49. In the event of a 30 day or more quarantine will you consent to allowing the tribe to pick up your medication on your household’s behalf?

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* 50. Are you frequently washing your hands?

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* 51. In the past 45 days have you or a member in your household been ill with a fever, cough or sore throat?

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* 52. Are you currently practicing social distancing?

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* 53. Are you currently practicing self-quarantine?

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* 54. Has anyone in the home been diagnosed with COVID-19?

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* 55. Would you like additional information on COVID-19?

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