Fillable COVID 19 Burns Paiute Tribal Community Needs Assessment (BURNS PAIUTE TRIBE)

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COVID 19 Burns Paiute Tribal Community Needs Assessment (BURNS PAIUTE TRIBE)

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The COVID 19 Burns Paiute Tribal Community Needs Assessment (BURNS PAIUTE TRIBE) form is 8 pages long and contains:

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1
COVID – 19 Burns Paiute Tribal Community Needs
Assessment
Where do you live?
_____ Burns Paiute Reservation
_____ Burns
_____ Hines
What is your current Gender Identity?
______ Female
______ Male
______ Two Spirited
______ Not Listed
Including yourself, how many people live in your household?
0-17 #_____
18-34 # _____
36-49 # _____
50+ # _____
Are you currently facing housing instability or homelessness?
Yes
No
If so, where are you living? _______________________________________________________________
✔
1
2
How many families live in your household?
1
2
3 or more
Wha
t is your employment status?
Full time
Part time
Seasonal
Self-Employed
Retired
Self-Employed
Has your Employment been impacted by Covid -19?
Yes, Less Hours
Yes, Laid Off
Yes, Teleworking
Yes, Administrative Leave
No
No applicable
A
re you or anyone in your household pregnant?
Yes
No
Don’t know
✔
✔
3
Have you experienced any of the following in relation to the Cornavirus (Covid 19) Outbreak? Check
all that apply
_____ Fear and worry about your health or the health of your loved ones
_____ Changes in sleep or eating patterns
_____ Difficulty sleeping or concentrating
_____ Worsening or chronic health problems
_____ Increased use of alcohol, tobacco, or other drugs
Overall how would you rate your mental health:
_____ Excellent
_____ Average
_____ Poor
_____ Not sure
Please describe what you are experiencing, have you reached out and received the help you needed.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Over the last month, have you been bothered by any of the following problems? Check all that apply
_____ Little interest or pleasure doing things you like
_____ Feeling down, depressed, or hopeless
_____ Trouble falling asleep, or sleeping to much
_____ Feeling tired or having little energy
_____ Poor appetite or overeating
_____ Feeling bad about yourself
_____ Trouble concentrating on things
_____ Thoughts of hurt yourself
_____ Thoughts of hurting others
✔
4
_____ Withdrawing from other people
_____ Depressed Mood
_____ Rapid Mood Changes
_____ Anxiety
_____ Difficulty leaving your home
_____ Outbursts of anger
_____ Spending increased time alone
_____ Feeling Numb
_____ Irritability
_____ Panic Attacks
(In your own words, describe the current problems you are experiencing if any)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
In what way would you like or need help, or are you currently receiving the help you need?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
In the past month have you been a victim of:
_____ Verbal Abuse
_____ Psychological Abuse
_____ Sexual Abuse
_____ Physical Abuse
_____ Stalking
Describe the last incident of physical, sexual abuse or stalking:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5
Have you reported the incident to law enforcement?
____________________________________________________________________________________
Will you be in need of any services? ______
Describe any specific area in which you need service.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you or any other members of your household been told that he/she has:
Asthma/COPD/Emphysema yes no don’t know NA
Diabetes yes no don’t know NA
Developmental Disability yes no don’t know NA
Hypertension/Heart Disease yes no don’t know NA
Immunosuppressed
Suppression of the immune
system and its ability to fight
infection.
Immunosuppression may result yes no don’t know NA
from certain disease such as AIDS
or lymphoma, or from certain
drugs, such as some of those
used to treat cancer
Do you or any member of your household need:
Daily Medication (Other than vitamins) yes no don’t know NA
Dialysis yes no don’t know NA
6
Home Health Care yes no don’t know NA
Oxygen supply yes no don’t know NA
Wheelchair/Cane/Walker yes no don’t know NA
Other (Please Specify) yes no don’t know NA
H
as your Household created a Household Plan of Action in the event of an outbreak of Covid-19 in
your community?
Yes
No
Does your household currently have a 30 day supply of medication for each person who takes
prescribed medication?
Yes
No
Don’t now
Not Applicable
Does you household currently have a supply of food for:
A few days
A week
A month
Month +
Are you experiencing a food shortage, meaning not knowing where your next meal is coming from, for
a period lasting more than two weeks?
Yes
No
Have you been voluntarily eating less than you need?
Yes
No
7
Where do you normally get your food?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have barriers in getting food, supplies, medication or other essential services?
Yes
No
How much of the each of the personal hygiene items do you have on hand?
Hand Sanitizer None Some Plenty Don’t Know N/A
Shampoo/Conditioner None Some Plenty Don’t Know N/A
Toothpaste None Some Plenty Don’t Know N/A
Toothbrush None Some Plenty Don’t Know N/A
Infant Wipes None Some Plenty Don’t Know N/A
Adult Support Wear None Some Plenty Don’t Know N/A
Feminine Products None Some Plenty Don’t Know N/A
Face Masks None Some Plenty Don’t Know N/A
Latex Gloves None Some Plenty Don’t Know N/A
Do you have any of the items listed below?
Hand Soap None Some Plenty Don’t Know N/A
Toilet Paper None Some Plenty Don’t Know N/A
Laundry Detergent None Some Plenty Don’t Know N/A
Cleaning None Some Plenty Don’t Know N/A
Disinfecting Supplies None Some Plenty Don’t Know N/A
Tissues None Some Plenty Don’t Know N/A
Cold/Flu Medications None Some Plenty Don’t Know N/A
(e.g. Tylenol, Mucinex)
8
Traditional Medicines None Some Plenty Don’t Know N/A
Do you have a First Aid Kit?
Yes
No
Don’t know
Do you have a Thermometer?
Yes
No
Do you have an emergency supply kit?
Yes
No
Don’t Know
What are your greatest strengths? (Check all that apply)
Culture
Education
Resiliency
Community
Family
Other
What is your household’s greatest at this need time?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Is there anything else you feel is important that you would like to share?
_____________________________________________________________________________________
_____________________________________________________________________________________
Testing the document
9
Upon completion of this form, you may email it back to Administration by clicking on the button
below.
Alternately, you may call Beverly Beers in Administration, 541-573-8016, and give her your answers
over the phone.
Thank you for your assistance and cooperation in this matter.
Click below
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COVID 19 Burns Paiute Tribal Community Needs Assessment (BURNS PAIUTE TRIBE)

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Completed 17 November 2021

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