Welcome to the Coronavirus‌ ‌|‌ ‌COVID-19‌ Community Impact Survey

Hello fellow community member!

We want to know what needs have arisen as a result of the Coronavirus | COVID-19 impacting the Houston-Galveston region. You are invited to fill out this community needs assessment. The information you provide will be used to help the non-profit, educational, and philanthropic communities understand the economic needs of households affected by Coronavirus‌ ‌|‌ ‌COVID-19‌ through loss of wages, loss of employment, or lack of resources due to household isolation. It will also be used to inform future response efforts. The survey should take 15 mins. to complete and has some optional demographic questions at the end. We appreciate your effort to help those in our community affected by Coronavirus‌ ‌|‌ ‌COVID-19‌. Thank you! Please note: This is not an application for medical help. If you or someone you know is sick, please call your doctor or primary health care provider. If it is an emergency, please dial 9-1-1. This is not an application for financial assistance or other resources. If resources become available to assist those affected economically by Coronavirus‌ ‌|‌ ‌COVID-19‌, we will reach out to share information about those resources.


To begin this survey, please click "Next Page"

Impact of the Coronavirus‌ ‌|‌ ‌COVID-19‌ on the Household

The Coronavirus | COVID-19 can have many different impacts. How has the Coronavirus | COVID-19 impacted your household in the past two weeks and what are the needs of your household? Select all that apply. 








Impact of the Coronavirus‌ ‌|‌ ‌COVID-19‌ on the Household


Please include all household members when reporting the Household Composition 






Adult Household Member Information

Please complete the following section for primary household member















Please complete the following section for second (2nd) adult in the household















Please complete the following section for third (3rd) adult in the household















Please complete the following section for fourth (4th) adult in the household















Please complete the following section for fifth (5th) adult in the household















Child Household Member information


Please complete this section for the oldest child in the household.



Please complete this section for the second (2nd) oldest child in the household.



Please complete this section for the third (3rd) oldest child in the household.



Please complete this section for the fourth (4th) oldest child in the household.



Please complete this section for the fifth (5th) oldest child in the household.



Household Demographics (Optional)

All of the questions in this section are optional











Release and Certification

Household Information
NOTE: The address information will help let organizations know where needs exist throughout the region. The address data will not be used for any other purpose.





Form Filler Information









Primary Household Member Information