COVID-19 Impact Assessment Survey
Full Name
First Name
Last Name
Email Address
example@example.com
How has COVID-19 affected your employment status?
No change
Reduced hours
Temporary layoff
Permanent layoff
New job
Other
Have you experienced any health issues related to COVID-19?
Yes
No
If yes, please describe your health issues.
How has COVID-19 impacted your mental health?
No impact
Mild impact
Moderate impact
Severe impact
Have you received COVID-19 vaccination?
Yes
No
Any additional comments or concerns?
Submit
Should be Empty: