Jacksonville Urban league COVID-19 Impact Survey

Staff name*

First Name Last Name

Affiliate

Today's Date*

Client name*

Email*

Phone*

Family Member

Relationship

Family Member

Relationship

Family Member

Relationship

Family Member

How many people live in the client's household?*

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

How many people Live in the client’s household?

What is the age range of people living in the client's home?*

What is the combined household income?*

Has the client lost or anticipate losing wages as a result of the COVID-19 (Coronavirus)?

Yes No

If yes, approximately how much in wages per week has the client lost or anticipates losing?

Has the client's personal household been impacted by COVID19 in any of the following areas: Check each that apply

Health

Childcare

Economic

HOW CAN WE HELP YOU?

Other needs (please specify)

Description

Which of the following are available in the clients home?

Cell phone with text capability Smart phone with 4G or 5G capability Electronic tablet (Ipad, Surface, etc.) High-speed internet Laptop or desktop computer Standard apps for smart phone

HOW DID the Client HEAR ABOUT US?

Method

The information provided through this survey will allow our staff to determine, assess and address your needs due to the impact of the COVID 19 pandemic.