COVID-19 Impact Survey COVID-19 Impact Survey YWCA McLean County has always served our community and clients by assessing needs, building capacity to address those needs, and partnering with others to ensure high-quality service. Responding to the COVID-19 outbreak is no different. We’re asking clients to share information and stories about how the crisis is impacting you and your families. We’ll use this information to guide our services, share information with elected officials and community partners, and advocate for support to address the community needs. You don’t have to answer anything you don’t want to, but please know that all of the questions will help us provide important information as we advocate for the community needs. All of your answers will be confidential and we will not share identifying information outside of our YWCA staff unless you give us permission to do that. Step 1 of 5 20% Are you a YWCA McLean County employee completing this information on behalf of a client?*YesNo Staff Entry FormThis form is being filled on behalf of someone who receives services through YWCA McLean County.What is your name?*Please list the name of the staff member filling out this form on behalf of a YWCA McLean County client. First Last Client DemographicsName First Last Email Mailing AddressWe’ll use this to identify the ward and congressional district. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What YWCA McLean County services do you use?Please mark as many that may apply. Labyrinth RSVP (Retired Senior Volunteer Program) Stepping Stones Young Wonders Early Learning Young Wonders Youth Development GenderManWomanNon-binaryPlease select the race(s) and ethnicity(ies) you most closely identifies with American Indian or Alaska Native Asian Black or African-American Latinx, Latina, Latino, or Hispanic Middle Eastern or North African Native Hawaiian or Pacific Islander White Other AgeWhat is your current housing situation?Staying in a shelterStaying with family/friendsRent your homeLease your homeOwn your homeHow many people live in your household?What is the employment status that best describes you currently?Employed, Full-timeEmployed, Part-timeNot Currently EmployedRetiredStudentLaid OffAre you a single parent?YesNo Impact Related QuestionsHow are you and your family doing? How has COVID-19 and the stay at home order impacted you and your household?Examples: Financial, Employment, Physical Health, Mental Health, Wellness, Sense of SafetyWhat needs do you have right now?Examples: Food, Health Care, Child Care, Rent Assistance, Help Navigating Forms/Government Processes, EmploymentWhat needs do you think you'll have in the coming weeks?How could YWCA help you and your family?How could our elected officials help you and your family?Are you okay with YWCA using your name when we share your story/impact/needs with other community and advocacy partners and elected officials?YesNoAre you okay to receive a call in a couple weeks for us to check in?YesNoIs there anything else you would like to share with us? 2020 Census QuestionsHave you received the 2020 Census form yet?YesNoUnsureHas the client received the 2020 Census form yet?YesNoUnsureHave you completed the 2020 Census?YesNoHas the client completed the 2020 Census?YesNoDid you know you can complete the census at my2020census.gov?Consider completing the census online at my2020census.govYesNo Staff QuestionPlease respond to the following question if you are the staff member filling this form out for a client.Is there anything else you would like to share with YW staff about this call or client?Example: If you think this story stands out or highlights needs in a meaningful way, include that here.