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Prevention COVID-19 Needs Assessment
1.
How much do you know about COVID-19?
Very little
Some
I would like to know more
I make an effort to educate myself
2.
Please check the items you are doing on a regular basis due to COVID-19.
Washing hands regularly
Practicing Social Distancing
Wearing a mask in public
Using hand sanitizer
Keeping my home and my belongings disinfected
Staying home more frequently
Working remotely from home
3.
Health concerns. Please check all that apply.
Members of my household becoming infected
Mental health concerns for my family and or myself
Substance use concerns for family and or myself
Concerned about the health of an older family member in a facility
Concerned about abuse going on in your home
4.
Basic need concerns. Please check all that apply.
Lack of food
Unstable housing situation
Difficulty paying for basic utilities
Lack of proper supplies to keep safe (mask, disinfectant, hand sanitizer, thermometer)
Lack of health insurance
Lack of income and or financial resources
Difficulty paying for prescriptions
5.
Technology concerns related to education and work.
Lack of Internet access for my child’s education
Lack of Internet access for my job
Lack of computer or other devices for my child
Lack of computer or other devices for myself
6.
Education concerns. Please check all that apply.
Do you worry about your child has fallen behind academically?
Are you concerned with the possibility of your child returning to school in the Fall?
Do you have concerns about how your child will respond to going back to school?
7.
Did you lose your job due to COVID-19?
Yes
No
8.
Are you receiving unemployment benefits?
Yes
No
9.
Do you need childcare?
Yes (ages 6-weeks to 3)
Yes (preschool ages 3-5)
Yes (after school ages 6-12)
No
10.
Do you plan to or have you been going out to do any of the following on a regular basis? Please check all that apply.
Eat in a restaurant
Go to the movies
Go to a park
Go to a gym
Meet with friends
Shopping in a retail store, not a grocery store
11.
What type of information would help you and your families? Please check all that apply?
More up to date information about COVID-19 and how to protect yourself and your family
Information about coping, stress and mental health
Information about resources within your community
Information about state, government and other agency’s assistance
Information about ways to entertain my children
Information about nutrition and how to feed my family healthy foods with limited resources
Emotional support from others with shared interests and concerns
Information about how to help myself cope
Information about how to help my young children cope
Information about how to help my teenager cope
Information to help an elderly parent or relative or friend cope
Other
12.
Where do you get most of your information about COVID-19 and how it is affecting your community, our country and the world? Please check all that apply.
Local television news
Local Radio Stations
Local town hall and city council meetings
Local Chamber of Commerce
Local medical doctors and hospitals
School Districts
Churches
National television news
National press conferences
Social Media
Government sponsored websites
Your employer
13.
What County do you reside in?
Erath
Hood
Johnson
Palo Pinto
Parker
Somerville
Wise
Other (please specify)
Current Progress,
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