COVID-19 Impact Survey

The COVID-19 pandemic continues to inflict a dreadful toll on the nation.  And government measures to contain the virus continue to stagger the nation’s economy.  A double-whammy of historic proportions.  How has it affected you?  Please answer the following:

Demographics information:

Please complete the next few questions about where you currently live, race, age, gender, and estimated income.

Your County: *LeeRussell

Your City: *AuburnOpelikaHurtsburoOther

If other, please list:

Your Zip Code: *

Gender: *MaleFemale

Marital Status: *SingleMarriedSeperatedDivorcedWidowed

Total number of people living in your household: *

Ages of each person living in your household: *

Ages

Ages

Numbers

Numbers

Numbers

Numbers

Numbers *

Numbers *

Your monthly household income: *$500 or less$501 - $1000$1001 - $1500$1501 - $2000over $2000

Race: *American Indian/Alaska NativeArab AmericanAsian AmericanNative Hawaiian/Other Pacific IslanderBlack/African AmericanWhiteOther

If other, please specify:

Hispanic/Latino: *YesNo

How has COVID-19 affected you and your Household:

1. Due to school and childcare closings, are you or anyone in your household having to stay at home and care for the children in your household instead of going to work? *YesNo

1a. If school and childcare opens, would you return to work?

• A. Yes, I will return to work
• B. No, I do not want to put my child in school/daycare
• C. No, I am concerned about returning to work
• D. No, I no longer have a job to return to
• E. other

1b. If other, please specify:

2. Have you or anyone in your household tested positive for COVID-19? *YesNo

2a. If yes, how many:

2b. Did anyone have to be hospitalized? *YesNo

2c. If yes, how many:

2d. If yes, please list their age(s):

2e. Did anyone die from the virus? *YesNo

2f. If yes, how many:

2h. If yes, please list their age(s):

3. Have you or anyone in your household been laid off from a job due to the economic shutdown? *YesNo

3a. If yes, how many:

3b. Will those who have been laid off be able to return to their job at some point?

• A. Yes, I have already returned to work
• B. No
• C. Don't know yet
• D. Yes, expected to return

4. Is your household’s total monthly income less now than it was prior to the economic shutdown? *YesNo

4a. If yes, how much less:

5. If your household’s income has decreased during the economic shutdown, which, if any, of the following apply to your household?

• Missed rent payment
• Missed mortgage payment
• Missed utility bill payment
• Missed phone bill payment
• Missed credit card payment
• Missed car payment
• Have had to cut back on food spending
• Have had to cut back on clothing spending
• Missed payment of something else
• Have had to cut back spending on something else
• None of the above

6. Have you or anyone in your household received a COVID-19 stimulus check from the government?

• A. Yes
• B. No
• C. Supposed to get one, but haven’t received it yet

7. Have you or anyone in your household received any type of assistance—financial or otherwise—from any government, church, non-profit, etc. entity during the COVID-19 crisis? *YesNo

7a. If yes, what type of assistance:

7b. If no, please specify:A. Did not requestB. Applied but turned down

7c. Please list the type of assistance you were turned down:

7d. Please state the reason:

8. Please describe what impact has the COVID-19 crisis had on you and your household.

9. What are you and your household’s greatest needs during the COVID-19 period? (including non- financial needs)

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