Form Small Business Pul Small Business Pul Small Business Pulse Survey

For the completion of this survey, please provide data for: XXXX
Is XX-XXXXXXX the Employer Identification Number (EIN) used on this businesses latest
Internal Revenue Service Form 941, Employer's Federal Quarterly Tax Return?

o Yes
o No
If no, please provide EIN:

Overall, how has this business been affected by the Coronavirus pandemic?

o Large negative effect
o Moderate negative effect
o Little or no effect
o Moderate positive effect
o Large positive effect
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In the last month, what were the total operating revenues/sales/receipts for this
business, not including any financial assistance or loans?

o $0 - $500
o $501 - $2,500
o $2,501 - $5,000
o $5,001 - $15,000
o $15,001 - $50,000
o $50,001 - $125,000
o $125,001 - $200,000
o $200,001 - $500,000
o $500,001 or more
o Don’t know
In the last week, did this business have a change in operating revenues/sales/receipts,
not including any financial assistance or loans?

o Yes, increased
o Yes, decreased
o No

In the last week, did this business do any of the following?

o Open a previously closed location
o Temporarily close a location
o Permanently close a location
o None of the above

In the last week, did this business have a change in the number of paid employees?

o Yes, increased
o Yes, decreased
o No

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The White House declared a national emergency because of the Coronavirus pandemic
on March 13, 2020
In the last week, did this business re-hire any paid employees who had been
furloughed or laid off after March 13, 2020?

o Yes
o No
o This business did not furlough or lay off any paid employees after March 13,
2020.

In the last week, did this business have a change in the total number of hours worked
by paid employees?

o Yes, increased
o Yes, decreased
o No change
In the last week, did this business have a change in the total number of hours paid
employees worked from home?

o Yes, increased
o Yes, decreased
o No change
o This business does not have paid employees who work from home
In the last week, did this business have any of the following?
Select all that apply:

o Domestic supplier delays
o Foreign supplier delays
o Difficulty locating alternate domestic suppliers
o Difficulty locating alternate foreign suppliers
o Production delays at this business
o Delays in delivery / shipping to customers
o None of the above
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In the last week, was this business's operating capacity affected by any of the
following?
Note: Operating capacity is the maximum amount of activity this business could
conduct under realistic operating conditions.
Select all that apply:

o Ability to re-hire furloughed or laid off employees and/or hire new employees
o Availability of employees to work
o Ability of employees to work from home
o Physical distancing of employees
o Physical distancing of customers or clients and/or limits on the number of
concurrent customers or clients

o Availability of Personal Protective Equipment (PPE) and/or related equipment
or supplies

o Availability of other supplies or inputs used to provide good or services
o None of the above
How would you describe this business's current operating capacity relative to one year
ago?
Note: Operating capacity is the maximum amount of activity this business could
conduct under realistic operating conditions.

o Operating capacity has increased 50% or more
o Operating capacity has increased less than 50%
o No change in operating capacity
o Operating capacity has decreased less than 50%
o Operating capacity has decreased 50% or more

4

How would you describe the current availability of cash on hand for this business,
including any financial assistance or loans?
Currently, cash on hand will cover:
Select only one:

o 1-7 days of business operations
o 1-2 weeks of business operations
o 3-4 weeks of business operations
o 1-2 months of business operations
o 3 or more months of business operations
o No cash available for business operations
o Don’t know
The White House declared a national emergency because of the Coronavirus pandemic
on March 13, 2020.
Since March 13, 2020, has this business missed any loan payments?
Loan payments that have been forgiven or postponed should not be considered to be
missed.

o Yes
o No
Since March 13, 2020, has this business missed any other scheduled payments, not
including loans?
Examples of other scheduled payments include rent, utilities, and payroll. Scheduled
payments that have been forgiven or postponed should not be considered to be
missed.

o Yes
o No

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Since March 13, 2020, has this business requested financial assistance from any of the
following sources?
Select all that apply:
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Paycheck Protection Program (PPP)
Economic Injury Disaster Loans (EIDL)
Small Business Administration (SBA) Loan Forgiveness
Main Street Lending Program
Deferral of Federal Employment Tax Deposits and Payments
Federal Sick and Family Leave Tax Credits
Federal Employee Retention Tax Credit
Other Federal programs
State or local government programs
Banks
Self
Family or friends
Other sources
This business has not requested financial assistance from any source since
March 13, 2020.

Since March 13, 2020, has this business received financial assistance from any of these
programs from the Federal government?
Select all that apply:
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Paycheck Protection Program (PPP)
Economic Injury Disaster Loans (EIDL)
SBA Loan Forgiveness
Main Street Lending Program
Deferral of Federal Employment Tax Deposits and Payments
Federal Sick and Family Leave Tax Credits
Federal Employee Retention Tax Credit
Other Federal programs
This business has not received financial assistance from any Federal program
since March 13, 2020.

6

Since March 13, 2020, has there been an increase in this business's use of online
platforms to offer goods or services?

o Yes
o No
o This business does not use online platforms to offer goods or services.
In the next 6 months, do you think this business will need to do any of the following?
Select all that apply:
□ Obtain financial assistance or additional capital
□ Identify new supply chain options
□ Develop online sales or websites
□ Increase marketing or sales
□ Learn how to better provide for the safety of customers and employees
□ Identify and hire new employees
□ Permanently close this business
□ None of the above
In your opinion, how much time do you think will pass before this business returns to
its normal level of operations relative to one year ago?
Select only one:

o 1 month or less
o 2-3 months
o 4-6 months
o More than 6 months
o I do not believe this business will return to its normal level of operations.
o This business has permanently closed.
o There has been little or no effect on this business's normal level of operations.
o This business has returned to its normal level of operations.

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Would you like to provide any information about your responses to these questions or
this business's experiences during the Coronavirus pandemic?
Remarks (500 characters)

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Census Bureau pre-decisional

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