Introduction/Demographics

The Allen County Department of Public Health is gathering information about the impact of COVID-19 and the needs within our community. This is an anonymous survey. It should take you 3-5 minutes to complete.

If you have an immediate need, please call 2-1-1.

The answers you provide will be used by the Allen County Department of Health and other partners to identify needs within the community. The collective results from this survey (no individual results will be shared) maybe shared for greater awareness or used for research.

If you are taking this survey on behalf of someone else, please answer all questions from their perspective.  Thank you!

Versión en Español

မြန်မာဘာသာ

Question Title

* 1. Who is taking this survey? (Check all that apply)

Question Title

* 2. What is the zip code of the household?

Question Title

* 3. What is your gender ?

Question Title

* 4. What is your race? (Check all that apply)

Question Title

* 5. For your household, how many people do you have in the following categories:

Question Title

* 6. How many weeks could you financially sustain your household if your workplace closed and/or you received no additional pay? Think carefully about the collective needs of your household (e.g. food, pets, utilities, toiletries, etc.).

T