Please help us with this CONFIDENTIAL survey to understand how the present Covid-19 virus emergency will affect your family.  Please answer the questions as they apply only to you and your household - thank you 

For  information or help with this survey contact:-

Amie Gardner / Danielle Ford

contact@evebransonfoundation.org.uk

Privacy policy - https://www.evebransonfoundation.org.uk/privacy-policy

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* 1. Today's date

Date

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* 2. Given Name

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* 3. Family Name

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* 4. Age

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* 5. Address

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* 6. Gender

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* 7. How many dependents, including yourself,  do you support in your household?

  number
Children under 1 yr
Children 1 yr to 3 yr
Children 4 yr to 6 yr
Children 7 yr to 10 yr
Children 11 yr to 17 yr
Adults 18 yr to 25 yr
Adults 26 yr to 35 yr
Adults 36 yr to 45 yr
Adults 46 to 69  yr
Adults 70 yr and over

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* 8. Is anyone in your household pregnant?

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* 9. What are the health concerns / disabilities among you and your dependents?  Please list

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* 10. What is the family's MAIN source of income?

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* 11. How has your MAIN source of income been affected?

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* 12. Do you have any loans that need to be repaid?

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* 13. How much money (Moroccan Dirham) do you need each month to survive (put food on the table & clothe your children)?

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* 14. If you receive FREE healthcare, how much money (Moroccan Dirham) do you need each month to survive and educate your children?

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* 15. If you pay for healthcare, how much money (Moroccan Dirham) do you need each month to survive and educate your children?

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* 16. Do you employ staff in your own business?

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