Online COVID-19 Survey Form (English)

NHSSF COVID-19 Survey

How are you being impacted by the Covid-19 pandemic?

Intro

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Question 7

Question 8

Question 9

Question 10

Question 11

Question 12

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Intro
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12

Click ‘Next’ to begin

1. What have you done professionally until now?*

A) I’m a regular employee.

B) I own a business with employees.

C) I’m self-employed (I am a consultant, work in the gig economy, etc.)

D) Other

2. Which are the most drastic consequences you are facing during this crisis? *

Choose up to 3 options

A) I cannot pay my mortgage (and I am afraid of losing my home).

B) I cannot pay my rent (and I am afraid of losing my home).

C) I have been laid off.

D) I’m still working but lost income from a part-time job and/or overtime pay.

E) I need to adapt to a home-office or a home-schooling routine (e.g., no daycares available; no one to leave my children with while I’m at work).

F) I lost my (or my family’s) medical coverage/services while confined.

G) I had to shut down my business.

H) I had to dismiss nonessential staff (I’m barely operative).

I) I can’t pay the payroll/benefits of my employees.

J) Other

3. Do you or your family (children, elders, partner) need assistance in the short term? *

Choose the 2 most urgent options

1) Food for my family

2) Medication for a family member

3) Financial help to comply with rent, loans, lines of credit, etc.

4) Help to keep my mortgage (loss mitigation for foreclosure prevention)

5) N/A

6) Other

4. If you are employed and you lost your primary source of income due to the pandemic. Are you claiming (do you qualify) for unemployment compensations? *

Yes

Unsure

N/A

5. Would your household still be in danger even after getting unemployment compensation?*

Yes

Maybe

N/A

6. If you are paying rent or a mortgage, could you continue making payments over the next few months, even after negotiating deferred payments with your landlord or lender?*

1 = not accurate at all; 5 = totally accurate statement

7. Would you need an emergency (affordable) place to go in case of eviction?*

Yes, I don’t have anywhere to go.

No, my family network will help me.

Maybe.

N/A

Other

8. If you are a businessperson that had to you shut down operations due to the pandemic, please rate your most pressing concerns on a scale of 1 to 5. *

1 (the least), 5 (the most)

	1	2	3	4	5	N/A
	1	2	3	4	5	N/A
Pay my employees.
Pay my rent.
Keep the (medical) benefits of my employees/myself in place.
Adapt my business to an online environment.
Pay my mortgage.
Pay my loans or lines of credit.
Pay utilities and other operational costs (like cleaning, landscaping, etc).

9. If your business is not operative right now, would you be able to relaunch activities as soon as the confinement measures are over? *

Yes, but I would need financial support.

Yes, but I would start with a shortage of staff/services.

No, it would take me a couple of months (and financial help) to get back on my feet.

No, I’m close to bankruptcy.

N/A

Other

10. Do you want us to contact you for any of the following services?*

Select up to 2 options

1) Financial fitness counseling

2) Foreclosure mitigation

3) Housing assistance (shelter, temporary housing, other)

4) Rental payment assistance

5) Mortgage payment assistance

6) Other government assistance program (TANF, WIC, etc.)

7) Bridge loans for businesses

8) No, thanks

9) Other

11. Do you want to tell us your story about how this pandemic is impacting your life?

Please elaborate

Type Here

12. Would you like NHSSF to provide additional services? If so, which type of services?

Please elaborate

Type Here

First Name

Last Name

Email Address

Phone

Yes, I (or a family member) will still be working.

Yes, I have savings for the upcoming months.

No, I don't have any other means to support myself (my family) after a certain period.

No, I will be in a very difficult situation.

Dear %NAME%,

Your response was submitted. One of our staff members at NHSSF will contact you in the future (if indicated).

Thank you very much for your time!
Keep you and your family safe!

NHSSF

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