VI Health & Wellness Needs Question Title * 1. Where do you reside? St. Croix St. Thomas St. John Question Title * 2. What is your gender? Female Male Other (specify) Question Title * 3. What is your current age? Under 18 18-29 30-39 40-49 50-59 60-69 70-79 80-89 90 or older Question Title * 4. What is your ethnicity? (Please select all that apply.) American Indian or Alaskan Native Asian or Pacific Islander Black or African American Hispanic, Latino/a, or of Spanish origin White / Caucasian Prefer not to answer Other (please specify) Question Title * 5. Disability type(s)? Acquired Brain Injury Autism Spectrum Disorder Deaf/Hard of Hearing Intellectual Disability Mental Health Condition Physical Disability Vision Impairment N/A Question Title * 6. COVID-19 vaccine status? Taken/Vaccinated Don't Trust Vaccines Using Other Methods of Prevention I would Rather Not Say Question Title * 7. Did you experience any negative symptoms from your COVID-19 vaccines or booster shot? Yes No Question Title * 8. Since COVID-19, what challenges have you experienced? Check all that apply. Domestic Violence/Abuse & Negelect Finding Employment Healthcare Information Related to COVID-19 Limited Social Interaction Loss of Employment N/A Question Title * 9. What are your needs/goals? Check all that apply. Access to Assistive Technology Communication Accommodation: Braille or ASL (American Sign Language) Employment Food Stamp Meals on Wheels Medical Healthcare Coverage Permanent Affordable Housing Primary Caregiver or Personal Assistant Transportation Question Title * 10. Are you familiar with the Disability Rights Center of the Virgin Islands (DRCVI)? Yes No Question Title * 11. If yes, how did you hear about DRCVI? Event Friend Radio Referral Social Media Question Title * 12. Would you like to receive information about home healthcare services? Yes No Done
