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English (US)
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Reviving & Rebuilding Rockland
Resident
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
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Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
1. How has the pandemic adversely affected you and your household?
*
Health (Mental Health, Healthcare, Access)
Financial (Employment, small business, bills, housing)
Community Services (Access, Availability)
Water and Internet
N/A
2. How was your HEALTH adversely affected by the COVID-19 pandemic?
*
Isolation
Depression/Anxiety/PTSD
Access to health care facilities/services
N/A
3. How were you FINANCIALLY affected by the COVID-19 pandemic?
*
Employment
Bills (rent, mortgage, utilities)
Basic needs (food, childcare, medical expenses, transportation)
N/A
4. Were there community resources that were not available to you due to the COVID-19 pandemic?
*
Food access
Medical/mental health
Transportation
Childcare
Employment opportunities
Housing
N/A
5. Did you seek any services at any time during the COVID-19 pandemic
*
Yes
No
5a. Who did you seek services from?
Government
Not for Profit
Faith- based organizations
N/A
Additional Comments (Optional)
Submit
Should be Empty: