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Application Questionnaire
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PART I. FINANCIAL NEED
1. How have you been most affected by COVID-19? Select all that apply.
Lost job
Lost wages
Furloughed
Uncertain about returning to job
Have health issues
Anxiety/Stress
Loss of Childcare/School
Cannot seek employment due to childcare responsibilities
2. What is your greatest financial need right now? Select Top Three (3).
Rent
Utilities
Food
Medication/Healthcare
Childcare
Remittances
Other
3. Have you applied for other services/resources? Select all that apply.
Unemployment Insurance (EDD)
Food Stamps (CalFresh)
Cash Aid (CalWORKS)
Other
None
4. Have you received any of the following services/resources? Select all that apply.
Stimulus Check (Economic Impact Payment)
Unemployment Insurance (EDD)
Food Stamps (CalFresh)
Cash Aid (CalWORKS)
Other
None
PART II. APPLICANT INFORMATION
5. What is your full legal name?
First Name
Middle Name
Last Name Name (Include second last name)
6. What is your address?
Street Address
City
County
-- Select Value --
Imperial County
Coachella Valley
Zipcode
State
Country
7. Mobile Phone
Phone #1
Phone #2
8. Email
9. What is your age?
10. What is your gender?
-- Select Value --
Female
Male
Nonbinary
Transgender
Decline to State
Other
Other Gender
11. What is your race/ethnicity?
-- Select Value --
Latino/Latina
Black
White
Asian/Pacific Islander
Indigenous
Multi-Racial
Purépecha
Is mailing Address Different?
-- Select Value --
Yes
No
PART III. HOUSEHOLD
12. How many people depend on your income, including yourself?
13. How many household members are 18 and over, including yourself?
14. How many household members are under 18?
15. Which languages are spoken at home?
-- Select Value --
English
Spanish
Other
Other Languages
16. In which COUNTRY were you born?
-- Select Value --
Mexico
Guatemala
El Salvador
Nicaragua
Honduras
United States
Other
Other Country Born
PART IV. EMPLOYMENT
17. What is your primary occupation?
-- Select Value --
Childcare
Domestic Work
Farm Work (Agriculture)
Food Processing
Healthcare
Hospitality
Janitorial
Gardening/Landscaping
Personal Care
Restaurant
Retail
Transportation
Other
Other Occupation
18. How long have you worked at this job?
Years
-- Select Value --
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Months
-- Select Value --
0
1
2
3
4
5
6
7
8
9
10
11
12
19. How long have you been out of work?
Days
-- Select Value --
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Months
-- Select Value --
0
1
2
3
4
5
6
7
8
9
10
11
12
Year
-- Select Value --
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
PART V. OTHER
20. Were you referred to this program?
-- Select Value --
Yes
No
By which organization(s)?
The Coronavirus is impacting families in many ways. We would like to learn more about ways our community is being impacted.
How has the Coronavirus (COVID-19) impacted you and your family?
Do you give us permission to share your story? (Identifying information will not be shared)
-- Select Value --
Yes
No
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