COVID-19 Business Impact Assessment Survey

2.

((If open))

What is your current on-site operating level?

3. What is your current remote operating level? (100% normal)

4. What percentage of your supplies/services are you able to receive?

5. What percentage of your goods or services are you able to ship/deliver?

7. What was the date of closure?

8. What is your current full-time employee count? *This question is required.

9. What is your current part-time employee count? *This question is required.

12. What percentage of your workforce is currently working remotely? *This question is required.

13. What percentage of your workforce is unable to work remotely? *This question is required.

14. If employees are temporarily not reporting for work, what percentage will be paid during the work hiatus?

15. If any employees are temporarily not reporting for work, and are being paid, approximately how many weeks will they be compensated?

16. Is the company providing any temporary aid to unpaid employees during their furlough? *This question is required.

17. On a scale of 1-7 how would you evaluate workforce morale today?

1 low
7 Determined *This question is required.

18. In addition to general health, what is your greatest concern for employees during this time of emergency? *This question is required.

19. Has your company's weekly revenue experienced an increase as a result of COVID-19? *This question is required.

20. Has your company's weekly revenue experienced a decrease as a result of COVID-19? If yes, please estimate in revenue.

21. How many weeks of a business slow down or shutdown would you estimate your business could survive before closing?

22. Have you contacted your bank about a bridge loan or other financing? *This question is required.

23. What are your top three concerns looking forward? (Type only 3)

Decreasing consumer confidence/spending
Financial impact on operations and/or liquidity and capital
Global or US recession
Impact on tax and trade issues
Lack of information for decision making
Lower productivity
Supply chain disruptions
Workforce reduction
Employee stress
Other

*This question is required.

25. If you answered yes to question #24, what number is your expected workforce reduction?

27. If you answered yes to question #26, what number is your expected workforce reduction?

29. Is there a thought, concern, or action you would like to share or suggest? *This question is required.

30. Name *This question is required.

31. Business Name *This question is required.

32. Business Address *This question is required.

33. Zip/Postal Code *This question is required.

34. Email Address *This question is required.

35. Phone Number *This question is required.

36. Name your company's COVID-19 Customer Response Coordinator.

*This question is required.

37. Which one of the following best describes your organization's primary industry? (Type only 1)

Agriculture, Forestry, Fishing and Hunting (farming, crop production, animal production, fishing, etc.)
Mining, Quarrying, and Oil and Gas Extraction
Utilities
Construction
Manufacturing
Wholesale Trade (i.e. purchase or sale of goods for resale)
Retail Trade (i.e. auto dealers, furniture stores, hardware stores, grocery stores, pharmacies, gas stations/convenience stores, clothing stores, jewelry stores, gift stores, florists, office supplies, etc.)
Transportation and Warehousing (i.e. transportation services, warehousing and storage)
Information (i.e. newspapers, movie and sound recording, telecommunications, data processing and hosting)
Finance and Insurance
Real Estate and Rental and Leasing
Professional, Scientific, and Technical Services (i.e. legal services, accounting services, architectural and engineering services, computer system design services, consulting services, etc.)
Management of Companies and Enterprises (i.e. management and holding companies)
Administrative Support and Waste Management and Remediation Services (i.e. administrative and support services, employment services, business support services, travel agencies, security services, janitorial services, landscaping services, waste management services)
Educational Services (i.e. elementary and secondary schools, colleges and universities, technical and trade schools, and educational support services)
Health Care and Social Assistance (i.e. doctors and dentist offices, hospitals and clinics, home health care services, nursing care facilities, family services, child care services)
Arts, Entertainment and Recreation (i.e. performing arts, sports and fitness companies and facilities, artists, writers, performers, museums, tourism and historical sites, casinos, etc.)
Accommodation and Food Services (hotels, bed and breakfasts, restaurants, bars, caterers, mobile food services, etc.)
Other Services (i.e. automotive repair and services, equipment repair, barber/beauty shops, funeral services, dry cleaning, churches and religious organizations, civic and social organizations, business and professional associations, and labor union organizations
Public Administration (local, state and federal governments and organizations)
Other
Not Sure

*This question is required.