Corona Virus Survey

* Indicates required field

Name *

First

Last

Email *

Do you consent to RAMFEL contacting you by email? *

What is your preferred spoken language? *

How well can you understand English? (Select all that apply) *

I can read English I can write in English I can speak English

Address Line 1 *

Address Line 2 *

City *

Post Code *

Preferred Reading Language *

Do you feel like you adequate information about Corona Virus? (such as when to contact 111 or rules about COVID 19 such as the need to stay at home and social distancing)? *

If not, could you describe what information you need? *

Do you currently have any issue in getting food or medicine? *

If yes, what is your issue? *

Do you have anything you need to leave the house for other than food, medicine or exercise? *

Are you able to check email for regular information and messages from us? *

How much support do you receive per week? *

How many dependents / household family members do you have living with you? *

What kind of accomadation do you live in? (I.E. shared, private, Nass) *

If you live in shared accomadation, what facilities do you share with others? (Kitchen, Bathroom, Living Room, etc.) *

Are you able to self isolate in your accomadation? *

Are you registered with a local GP? *

Do you have a valid HC2 certificate or in receive of benefit that exempts them from paying health cost? (Such as - Universal Credit, Income Support, income-based Jobseeker's Allowance, income-related Employment and Support Allowance or the guarantee credit part of Pension Credit). *

Do you have any existing health issues, that put you at additional risk from coronavirus? *

If yes, could you explain the issue? *

Do you need help to convey any health issues to your GP? *

In what way do you need assistance? *

Submit