Business Impact Assessment
If your business has been impacted by COVID-19, please complete this form. You may also use this as a way to submit a question to the response team.

**Please feel free to submit this form multiple times with updated information and questions**

The results of this form will be shared with team members from the entities listed above, but will be kept confidential. Aggregate data may be shared with a larger audience, no personal or company details would be included. If you have any specific issues or questions with this form, call (812) 232-2391.

Sign in to Google to save your progress. Learn more
Individual Name: *
Business Name: *
Title:
Phone:
Email: *
Industry Type: *
What size business do you represent? (Full Time Equivalents)
How has your business been negatively impacted by COVID-19?
Has your business experienced any positive results as a result of COVID-19?
Clear selection
Have you been forced to lay-off employees and/or reduce hours during the pandemic?
Clear selection
If yes, how many employees have been impacted? (Full Time Equivalents)
If yes, what percentage have returned to work?
Clear selection
Do you anticipate these lay-offs or reductions to be permanent?
Clear selection
What is your estimated revenue loss due to COVID-19?
Without financial assistance, how likely is it that your business will permanently close as a result of COVID-19?
How long do you think it will take for your business to return to pre COVID-19 sales and staffing?
Are you seeking immediate information? (A team member will follow-up with you in 1 business day)
What do you anticipate your long-term needs to be?
Additional questions or concerns you would like to have addressed?
Are you in need of masks for your workers and/or customers?
Clear selection
If yes, approximately how many masks will you need?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Terrehautechamber.com. Report Abuse
Google Forms