Personal Identification
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Name
First Name
Last Name
Email
Phone
(###)
###
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Household overview
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My household consists of (select one):
Household ages
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My household consists of (check all that apply):
Health status
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Select one
Health coverage
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Select one
Current employment status
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Someone in my household has become unemployed since the beginning of March, 2020.
Someone in my household is employed in one of these fields:
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Check all that apply
Employment Concern
These scales describe your concern about losing your job in the next four months.
I am concerned about losing my job in the immediate future (between now and two weeks):
I am concerned about losing my job in the near future (between two weeks and two months):
I am concerned about losing my job in mid future (between two months and four months):
Sufficiency Levels
These scales describe your confidence to remain self-sufficient in the event of a loss of employment.
If I were to become unemployed, I have the resources to remain financially stable for the foreseeable future:
If I were to become unemployed, I have the resources to remain financially stable for at least a month:
If I were to become unemployed, I would go into immediate debt (including credit cards) to pay for my daily expenses:
If I were to become unemployed, I would not be able to access the resources (including credit cards) to pay for my daily expenses:
Availability to help practically
I would like to know more about how I can help someone in the following areas:
Availability to help financially
Please check this box if you would like to be contacted by a pastor about how you can further help provide financial assistance to people in need.
If not, please leave blank.
Notes
Is there anything else that you would like us to know?
Permission to Contact
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Do you give permission for church staff to contact you? To do this, you must have provided your contact information above.
Check all that apply:
Non-Obligatory
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By responding to this survey, I am aware that I am not entering into any agreement, understanding or obligation for the church or any of its members to provide any goods or services to me.
Privacy
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Any responses submitted will be made available to a select group of church staff and advisors on a needs-to-know basis only. The names of these staff members and advisors are available upon request from the church.
