Prevention COVID-19 Needs Assessment Survey

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* 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

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* 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

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* 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

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* 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

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* 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

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* 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?

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* 7. Did you lose your job due to COVID-19?

Yes

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* 8. Are you receiving unemployment benefits?

Yes

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* 9. Do you need childcare?

Yes (ages 6-weeks to 3)

Yes (preschool ages 3-5)

Yes (after school ages 6-12)

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* 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

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* 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

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* 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

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* 13. What County do you reside in?

Erath

Hood

Johnson

Palo Pinto

Parker

Somerville

Wise

Other (please specify)