E.R.P Questionaire

Your First Name (required)

Your Last Name (required)

Your Phone no. (required)

Your Email: (required)

1. Are you the primary contact in the house hold? Yes or No. If No who is?

2. How many in the household?

2b. Please provide details.

3. Languages spoken & written in household?

4. Would you like to learn French or English?

5. Are any members of your house involved in fitness or exercise activities?

6. Are you seeking programs & activities in your community?
Yes or No. If yes what types of programs & activities are you seeking?

7. Are there senior activities available in your area?

8. Are you involved in any African/Caribbean cultural programs?
If no are you interested in culturally adapted programs?

9. Are you affiliated to a black community organization?
If yes please specify. If no are you interested in becoming affiliated to one?

10. Allergies, or medical information that we should be aware of?

11. Are you interested in information about natural medical treatments?

12. Do you suffer from stress or anxiety?

13. Do you have emergency food reserves?

14. Are you interested in planting or spending time in a green house?

15. Any mobility issues?

16. Do you have any special skills that can help in time of need ex: CPR certified, sign language?

17. Can you provide transport in time of need?

18. Would you volunteer to be a Head coordinate responsible for your surrounding area?
Yes or No. If Yes, do you have coordination experience?

19. Are you involved in your local politics?

20. Are you involved with a school committee?

21. Are you an entrepreneur or business owner?
If yes can your business sponsor items during crisis or prior to crisis to aid in preparation.?
Do you receive any business support or mentorship?
Can you benefit from marketing or administrative support?

22. Can you donate products or Money in support of this initiative? If Yes please specify

23. Do you work from home?

24. Are you seeking employment?

25. Do you have a landline or cell phone only?

26. Do you have the internet?

27. Who are your current providers?

28. Would you like information about possible savings available for your telecom services?

29. What are other things the OFC can help you with?

Additional Comments

OFC stands for?

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