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Survey COVID-19 UPDATE HCC SG
I). Name
*
First
Last
[object Object]
*
Indicates required field
II) What is your zip code area?
*
How many person(s) live in your household?
*
III) Email address
*
IV) Gender
*
1) Male
2) Female
3) In the process of a change
4) Other
V) What is your ethnicity?
*
1 African-American
2 Latino / Hispanic
3 Asian
4 White
5 Other: Two or more races
VI) Your age is between___?
*
1) 16-18
2) 19-25
3) 26-35
4) 36-50
5) 51-65
6) 66-90
7) Prefer not to say
VII) Your family income last year was between?
*
1) Prefer not to say
2) Less than $10,000
3) $10,001-$25,000
4) $25,001-$40,000
5) $70,001-$100,000
6) > $100,000
VIII) What is your current job status?
*
1) Unemployed
2) Part-time
3) Full-time
4) Self-employed
5) Housewife / husband
6) Full-time Student over 6 months
VIII) Have you been tested for the COVID-19?
*
1) Yes
2) No
3) Maybe
VX) What was the highest level of educational course you last completed?
*
1) High School Level
2) Community - Trade College Level
3) Bachelors College Level
4) Masters Level Class
5) Other
6) Doctoral Level Class
X) How often does your family save to have emergency crisis funds?
*
1) At least once per week for 6 months
2) Once per month for 12 months
3) About 2 to 3 months per year
4) Only one time in the year
5) You do not save
XI) When was the last time you visited a doctor?
*
1) Less than 5 days
2) Less than 6-9 weeks
3) Less than 6-12 months
4) Over a year
5) Over 5- 9 years
6) It has been to long to remember.
XII) What are the chance you or someone you know likely contact the COVID-19?
*
I) Highly likely
2) Somewhat likely
3) Unsure
4) Least Likely
5)Highly unlikely
XIII) How did you hear about the questionnaire?
*
1) Internet Search
2) Advertisment
3) Friend
4) Other
XIV) Please Specify: Who invited you, What school or how did you hear about the survey?
*
XV) Have you and your family been wearing face cover masks when you go out?
*
1 Yes
2 No
3 Sometimes
XVI) If you were tested positive for the COVID-19, what symbols did you have with the virus? enter NA if the question does not apply to you.
*
XVII) How are you feeling mentally? check all that are a concerny
*
1 having some anxiety
2 some what stressed
3 feeling depressed do not know how things will continue
4 Other
5 Okay, Taking things day by day
XVIII) How satisfied are you with the way the federal government has handle the current crisis?
*
1. Very Satisfied
2. Satisfied
3. Neutral
4. Unsatisfied
5. Very Unsatisfied
XIX) If possible: please share additional resources and tell us what you and others might need doing this COVID-19 crisis?
*
XX) Looking back on the last couple of crisis, how important do you think it would be for a family to try to save the 6 months recommended funds? Also considering, today times a family member could experience a lost of a jot, health issues or there could be another world crisis? Choose One
*
1. Very Important
2. Important
3. Neutral
4. Somewhat Important
5. Not at all Important
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