Mesa CARES - Individual Needs Assessment

Thank you so much for taking time to complete this assessment. We are using this information to get a better understanding of current needs in the community to help us grow services and programs as federal funds become available. 

 

1
In the local pandemic emergency, what services are most important to you?  (please add specific details)
  • Emergency response (police, fire, etc.)
  • Access to food (specify produce or dry goods, cans, meal boxes)
  • Access to medications/ pick-up or availability
  • Baby supplies (diapers, formula)
  • Rent assistance
  • Utility assistance
  • School resources/education
  • Child care
  • Loss of income/unemployment assistance
  • Support services for seniors/high risk (ex: grocery, prescription pick up)
  • Tax preparation stimulus form assistance
  • Mental health services
  • Access to household supplies (cleaning supplies, paper products, etc)
  • Other
2
How concerned are you with the following issues impacting your family/household in the coming months as a result of COVID-19?
  • 5=N/A
  • 4=Very Concerned
  • 3=Somewhat Concerned
  • 2=Slightly Concerned
  • 1=Not At All Concerned
  • 5
  • 4
  • 3
  • 2
  • 1
 
Members of my household becoming infected by COVID-19
 
 
Having enough food during the pandemic
 
 
Having enough household supplies during the pandemic (cleaning supplies, toilet paper, etc)
 
 
Helping my children with online schooling
 
 
Childcare
 
 
Economic impact on my household
 
 
Access to medical services (e.g., emergency care, basic medical care and needed prescriptions)
 
 
The emotional health of my household
 
 
The safety of my community during the pandemic
 
 
Ability to pay my rent or mortgage
 
3
If important information about COVID-19 and our community needs to be shared, which of the following do you rely on for updates?
  • Local television stations
  • Local radio stations
  • Local newspapers
  • Local government websites
  • Schools
  • Social media: (please specify Facebook, Nextdoor, Twitter, Instagram)
  • Other organizations (please specify churches, clubs, nonprofits, etc)
  • Other
4
Do you recommend anyone in your family or community that would take this survey to help us better understand the needs of the local community? Please provide contact info.
5
Is there anything else you would like to share with us?
6
Name:
7 *
Email (program and service updates may be sent out via email):
8
Phone:
9 *
Zip code:
10 *
Age Range:
  • 18-30 years old
  • 31-45 years old
  • 45-60 years old
  • 60 or older
  • Unavailable