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COVID-19 Needs Assessment (Community Members)
If you would like assistance completing this survey, please call or email using the contact information listed below.
1-800-686-1093 (HAPCAP Main Office)
740-767-4500
amanda.sawvel@hapcap.org
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Name
Your answer
Primary email address
Your answer
Primary phone number
Your answer
Age group
Under 18
18-24
25-34
35-44
45-54
55-64
65 or over
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Marital status
single
married
divorced
widowed
Other:
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Gender
male
female
Other:
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Race
White/Caucasian
Black/African American
Asian
American Indian/Alaskan Native
Hawaiian/Pacific Islander
Hispanic
Multiracial
Other:
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In which county do you live?
Athens
Hocking
Perry
Other:
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