EmailMeForm
COVID-19 Community Readiness Survey
The Allen County Department of Public Health is gathering information from the community to assess how prepared we are as a community to endure a local COVID-19 epidemic. The answers you provide will be used by the Allen County Department of Health and other partners to identify needs within the community. The results from this survey may be shared for greater awareness or used for research.
All responses are anonymous.
1. What zip code do you live in?
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2. How many people are there in your household?
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3. How many dependent children would you need to find substitute childcare for if schools and childcare facilities were closed?
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4. How many adults with special needs or need additional care would you need to find substitute care for if support/care facilities were closed?
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5. How many older individuals would you have to find substitute care for if eldercare services were closed?
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6. Do you or anyone in your household have a chronic condition that affects their immune system?
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Yes
No
7. How many weeks could you financially sustain your household if your workplace closed and you received no additional pay? Think carefully about the collective needs of your household (e.g. food, pets, utilities, toiletries, etc.).
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1-2 weeks
3-4 weeks
5-6 weeks
7+ weeks
8. Do you or anyone in your household depend on public transportation (e.g. city buses, Uber/Lyft, trains)?
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Yes
No
9. How many people in your household have NOT been vaccinated for influenza?
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[NOTE: an influenza vaccination is not a substitute for a COVID-19 vaccination. There is no COVID-19 vaccination at this point.]
10. Do you have an established health care provider for yourself (e.g. a provider you see regularly for health maintenance or illness)?
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Yes
No
11. Do you have an established health care provider for your dependents (e.g. a provider your dependent sees regularly for health maintenance or illness)?
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Yes
No
12. Do you currently have health insurance?
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Yes
No
13. Do you have the financial resources to pay for medical treatment if you or a family member were to become ill?
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Yes
No
14. What local resources would you use if you needed help with the items below? Check all that apply.
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None
Faith-Based (e.g. churches)
Community (e.g. neighbors, non-profits)
Government (e.g. Dept. of Health)
Corporate (e.g. healthcare/local businesses)
Friends/ Family
Not Sure
Stress/Emotional Support
Transportation
Food/Water
Healthcare
Utilities
Childcare
Adultcare
Eldercare
Other (please specify)
15. In the next 60 days, are you worried about your ability to find or purchase prescription medication for yourself or people in your household?
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Yes
No
Not Sure
Does not apply
16. Please check the categories of medications below that you or people in your household are currently taking:
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Please select
Blood thinners
Blood pressure
Diabetes
Heart failure
Mental health (e.g. antidepressant, ADHD, psychiatric disorders, etc.)
Cancer therapies
Pain medication
None / Doesn't Apply
Other (please specify)
Please specify
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17. In the next 60 days, are you worried about your ability to find or purchase food for yourself or people in your household?
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Yes
No
Not Sure
Does not apply
