Thank you for your time and effort in completing our survey.

PRIVACY POLICY: This questionnaire is intended to gather aggregate data. We will not disclose personal or financial information to any third party without your permission. Anecdotal comments you supply will only be quoted without attribution, to protect the identities of participating individuals. This is not an application for public or private assistance and responses have no bearing on any grant review process. Please note that only necessary personnel will become aware of your identity.

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Please tell us the address and zip code of your residence/living space
and your workspace/studio as indicated below.
Your Residence/Living SpaceYour Workspace/StudioDid/do you work at home?
Pre 9/11:Zip:Pre 9/11:Zip: YesNo
Post 9/11:Zip:Post 9/11:Zip: YesNo
If different, was your move disaster-related?YesNoIf different, was your move disaster-related?YesNo


 Are you an artist, crafts person, or technician engaged in the arts/entertainment related industries of NYC?YesNo


if yes, please indicate your artistic discipline(s); check all that apply.
DancePerformance Production
MusicPerformance Production
TheatrePerformance Production
Performance ArtPerformance Production
Film/VideoPerformance Production
PhotographyFine Commercial
Visual ArtsFine Commercial
Computer/Digital MediaFine Arts Commercial
Literature / Publishing
Other


Are you a member of a union or guild?		YesNoWhich ones?



Work Profile

1.  As a result of 9/11 and its aftermath, did you (check all that apply):
Become Unemployed Lose sales/income Lose Business Opportunities or Independent Contractor Jobs Lose hours on the job?


2.  Please help us estimate your losses from work you earn income from as a result of the events of 9/11 and its aftermath:

(A) Did you suffer one-time business losses as a result of 9/11 and its aftermath? This could be from cancelled contracts, loss of equipment or materials, uncollectable accounts, etc.		YesNo
If yes, what amount has not been covered by any source? (insurance, government assistance, etc.)?
Please estimate the amount. $


(B) Are you experiencing an ongoing reduction in your aggregate work-related income due to 9/11 and its aftermath? This could be from reduced wages or hours, cutbacks, reduced commissions or residuals earned, an overall reduction in bookings, etc.		YesNo
If yes, by what percentage is your total work related income down?    %

Please select an industry number from the list below and describe the source(s) of the losses you cited in 2(B):

Industry you were working inZip code(s) of one or more work locations. Write "u" if zip is unknown. Write "m" for multiple zips.Employee or
Self-employed/
Independent contractor?		Full Time or
Part Time?		Arts Related?Month and Year lost?
EmployeeSelf FullPart YesNo /
If "Other", please specify
EmployeeSelf FullPart YesNo /
If "Other", please specify
EmployeeSelf FullPart YesNo /
If "Other", please specify



Have the work or income sources lost because of 9/11 returned or the market for your sales/work rebounded?		YesNo
If so, approximately what month and year? / or, (not applicable)



3. Did you lose work or work-related income sources in 2001 prior to the attacks?		YesNoIf Yes, Please complete the chart:

Industry you were working inZip code(s) of one or more work locations. Write "u" if zip is unknown. Write "m" for multiple zips.Employee or
Self-employed/
Independent contractor?		Full Time or
Part Time?		Arts Related?Month and Year lost?
EmployeeSelf FullPart YesNo /
If "Other", please specify
EmployeeSelf FullPart YesNo /
If "Other", please specify
EmployeeSelf FullPart YesNo /
If "Other", please specify



4. Are you currently earning income from work you do, arts-related or not?		YesNo

    A. If yes, please indicate your primary source of work-related income by its industry.
    If "Other", please specify
Are you a:Full Time EmployeePart Time EmployeeSelf Employed/Independent Contractor
    Zip code(s) of one or more work locations. Write "u" if zip is unknown. Write "m" for multiple zips:
    When did this work situation begin? (month) (year) Is this job function arts related ?YesNo



    B. Please indicate your secondary source of work-related income by its industry.
    If "Other", please specify
Are you a:Full Time EmployeePart Time EmployeeSelf Employed/Independent Contractor
    Zip code(s) of one or more work locations. Write "u" if zip is unknown. Write "m" for multiple zips.
    When did this work situation begin? (month) (year) Is this job function arts related ?YesNo
    If you have other sources of work-related income, please explain:
    
5.  What do you think your prospects are for finding work now?
    ExcelentGoodFairPoorN/A


RECOVERY PROFILE
1. Did you have increased expenses as a result of 9/11 for relocation  : YesNo  cleanup: YesNo 
other (specify nature)

2. If you suffered a loss of income or increased expenses since 9/11, how have you met expenses? Please check all that apply:
    Use of personal savings (other than money markets or stocks/bonds/ other investments)
    Credit cards
       Money Market Account or CD (balance income)
    IRA
       Pension (401K 403B)
    Disaster Unemployment Insurance
       Regular Unemployment Insurance:  began collecting pre-9/11  began collecting post-9/11
    SSI
    Disability
    Insurance proceeds
    Income from stocks/bonds/other investments
    Liquidated stocks/bonds/other investments
    Rental income from real estate owned
    Rental income from real estate rented
       Income from real estate sold. Please indicate if:primary residence secondary residence business property other
       Took out or refinanced mortgage on real property:primary residence secondary residence business property other
    Sold other tangible property
       Trust (income principal)
    Gifts
       Loans (SBA Banks Friends and Family Other)
      Other


3. Please estimate how much, by percentage, you have spent down your resources since 9/11 %		 N/A


In the following section, we are attempting to assess the effectiveness of public and private relief efforts to-date:



4.  Have you applied to and/or received aid from FEMA? If so, please indicate which program you applied to, the status of your application and the number of months received:

      Temporary Relocation Expense Program:		DeniedPendingOn appealAwarded[No. Mos.:]
      If you were denied aid, was it for the reason that "Your losses were not a direct result of 9/11"?YesNo
      Other reason, please specify:

      Mortgage & Rental Assistance Program:		DeniedPendingOn appealAwarded[No. Mos.:]
      If you were denied aid, was it for the reason that "Your losses were not a direct result of 9/11"?YesNo
      Other reason, please specify:
       Given the recent changes in FEMA's eligibility policy, do you intend tore-open your case or
     apply for the first time to the Mortgage and Rental Assistance Program?

      Individual & Family Grant Progams:		DeniedPendingOn appealAwarded
      If you were denied aid, was it for the reason that "Your losses were not a direct result of 9/11"?YesNo
      Other reason, please specify:

5. If you received assistance from the Department of Labor, please indicate whether you received regular or disaster unemployment insurance, the status of your award, the number of weeks granted, and if you were denied aid, the reason specified.

       Disaster Unemployment Insurance:		DeniedPendingOn appealAwarded[# of Weeks Awarded:]
      Reason denied, please specify:

       Regular Unemployment Insurance:		DeniedPendingOn appealAwarded[# of Weeks Awarded:]
      Reason denied, please specify:

Have you applied to and/or received aid from other governmental, private, community, industrial or union relief agencies, funds or foundations?YesNo

If so, please check off the agency(ies):

CHARITIES
American Red Cross
Brooklyn Bureau of Community Service
Catholic Charities
Community Service Society
Protestant Welfare Society
Safe Horizon
Salvation Army
September 11 Fund
Other
GOVERNMENT GRANT PROGRAMS
NYC EDC's Lower Manhattan Grant Program
Dept. Of Justice Office of Crime
Empire State Development Corp. Grant Program
Food Stamps
Disaster Food Stamps
Lower Manhattan Small Bus. & Workforce Retention Project
Medicaid
Disaster Medicaid
WTC Business Recovery Grant Program
Other
LOAN PROGRAMS
Accion NY "American Dream Fund"
Bank Loan
REDAC
Renaissance EDC
SBA
Other
FOUNDATIONS
American Music Center Liberty Program
A.R.T./New York-Andrew W. Mellon Arts Relief Fund
Actors' Fund
Adolph & Esther Gottlieb Foundation
Craft Emergency Fund
Jazz Foundation of America
MusiCares
New York Arts Recovery Fund/NYFA
Pollock-Krasner Foundation
Other
UNIONS
Actors Equity Assn.
AFTRA
Screen Actors Guild
Local 802
Other
    
For each agency selected above, please specify below whether the application was or was not successful:

Agency NameStatus If denied, reason


Agency NameStatus If denied, reason


Agency NameStatus If denied, reason

OTHER SOURCE:

Agency NameStatus If denied, reason


6. Did you have debts/liabilities pre 9/11?		YesNoHave your debts/liabilities increased significantly since 9/11?YesNo


7. Are you facing eviction (or have you been evicted):
from residence?YesNo; from workspace?YesNo; From storage space?YesNo
Are you facing foreclosure (or has your mortgage been foreclosed): on residence?YesNo; on workspace?YesNo


HEALTH INSURANCE
1. Did you have health insurance prior to 9/11? YesNoIf yes, was your coverage (please check all that apply):
Single (for yourself only) Plan Single with dependants Provided by an employer Provided through union or guild
Provided through partner's plan Self-Paid (COBRA) Self-Paid (OTHER)
          Monthly fee paid by you and/or partner $

2. Did your health suffer as a consequence of 9/11? YesNo If yes, was it:RespiratoryPhysical injury
or Other (describe) Has it affected your ability to work?YesNo

3. Have you gotten treatment for this?YesNo

4. Did you lose or become ineligible for health insurance due to 9/11 and its economic aftermath?YesNo

5. Are you aware of the Entertainment Industry Health Insurance Enrollment Center located at the Actors' Fund of America where you can get health insurance counseling and application forms for government and private insurance programs?YesNo

6. Would you be interested in finding out more about this program? (A representative of the Actors Fund may contact you.)YesNo

7. Would you purchase health insurance coverage:
    A. as an individual if the monthly premium on a policy were (indicate highest possible cost range for you):
up to $50?$51 to $100?101-$200?$201-$300?$301 or more?
B. on a family plan if the monthly premium on a policy were (indicate highest possible cost range for you):
up to $100?101-$200?$201-$300?$301-$400?$401-$500?$501 to 600?$601 to 700?$701 to 800?$801 to 900?$901 or more?


JOB TRAINING AND PLACEMENT
     CWE can provide job counseling, training and placement to artists who are interested in supplementing their income through flexible employment in various fields where the need for additional workers exists. If you are interested in this program, please answer the following questions and indicate if you would like to be contacted by someone from CWE.

     Please indicate all of the following fields in which you have experience:

Teaching Commercial Driving
Social Work/social services Construction-related trades
Baking Health Care
Computers Utility Employment (e.g., Con Edison) trades
     Would you be interested in job training/certification and/ or job placement in any of the following areas?
     Please check all that apply:
Teaching Commercial Driving
Social Work/social services Construction-related trades
Baking Health Care
Computers Utility Employment

Please list any particular type of skills and training, in addition to those listed above, you feel would be beneficial:
    
6. Would you like to be contacted by CWE regarding job retraining or placement?YesNo
7. Would you like to be sent information about the results of this survey?YesNo


PERSONAL PROFILE
Please note that this section is optional. However, if you would like to find out about job retraining or placement, the health insurance program or the results of this survey, we need to know who you are and how to reach you. Otherwise, this information is not required.

Additionally, being able to quantify the general demographics of our survey sample (e.g. age, sex, zip code) will strengthen the validity of the survey. Therefore we hope that you will help us by providing it, even if you don't want to give us your name, address, phone number and e-mail.

Thank you for your cooperation. If you have any questions, please do not hesitate to call Amy Schwartzman Brightbill, Information Officer, New York Arts Recovery Fund at NYFA at 212-366-6900, x. 369.



Sex:malefemale      Age      Do you have dependants?YesNo#


Living Situation:		Single live aloneSingle live with othersMarriedOther (specify if possible)
Do you:OwnRentyour residence:      OwnRentyour workspace?


Name:
Mailing Address: Apt/Suite:
City State Zip
Telephone e-Mail address
 Daytime Evening Cell

Any other comments?