COV I D EMP LOYER CHECK I N
1) DO YOU LIVE SOMEWHERE WHERE YOU CAN SAFELY AND COMFORTABLY COMPLETE YOUR WORK RESPONSIBILITIES IN A REASONABLE AMOUNT OF TIME?
Yes No Prefer not to answer
2) IF YOU ANSWERED NO TO THE ABOVE QUESTION, DO YOU HAVE ANOTHER REMOTE WORK OPTION?
Yes No Not sure
3) IF YOU ARE ABLE TO CONDUCT YOUR WORK REMOTELY, ARE THERE MATERIALS OR EQUIPMENT YOU WOULD NEED? IF SO, PLEASE SPECIFY BELOW.
4) PLEASE RATE THE BELOW POTENTIAL CONCERNS/RISKS ACCORDING TO HOW YOU ARE PERSONALLY IMPACTED. (THIS QUESTION IS MEANT TO ASSESS HOW CERTAIN RISKS ARE DIRECTLY IMPACTING OUR STAFF. WE UNDERSTAND THAT ALL OF THESE RISKS ARE/SHOULD BE OF CONCERN TO ALL OF US, EVEN IF WE ARE NOT DIRECTLY IMPACTED. )
1: I am not personally concerned about this / I do not feel at risk. 2: I am somewhat concerned about this
3: I am very concerned about this 4: This is among my top concerns
Food insecurity / Access to affordable and nutritious food options Lack of / poor / insecure internet access
Housing instability Mental health issues Difficulty paying monthly bills Caregiving needs Loss of income (for self or other household members) Other (feel free to specify in comments below)
k.smith@bkcw.com I 405-306-4557
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