United for Ukraine

OMB #: 0970-0531

Expiration Date: 9/30/2025

Uniting for Ukraine (U4U) Survey

In what language do you prefer to complete the survey?

1) English

2) Ukrainian [TRANSLATE THIS ANSWER CHOICE INTO UKRAINIAN]

3) Russian [TRANSLATE THIS ANSWER CHOICE INTO RUSSIAN]

Consent Notice

The Office of Refugee Resettlement (ORR), U.S. Department of Health and Human Services, invites you to participate in a survey to identify recently arrived Ukrainian parolees’ needs for resettlement services. ORR will use collected data to inform program decisions to better serve the recently arrived Ukrainian parolees. You can find more information on Ukrainian assistance resources at https://www.acf.hhs.gov/orr/programs/refugees/ukrainian-assistance-resources.

This survey is voluntary and should take around 10 minutes to complete. The answers you give will be kept private and anonymous. Once you begin the survey, please do not close the webpage before you answer all the questions in the survey. Each answer will be submitted after you click “Next,” and you will not be able to go back or change your answers.

By clicking “Agree and Next,” you consent to participate in the survey.

Thank you for your participation.

In this survey, “U.S.-located supporter” refers to an individual located in the United States, who has filed Form I-134 agreeing to financially support Ukrainians and their immediate family members as part of Uniting for Ukraine.

1. HOUSEHOLD COMPOSITION

1. How many adult family members (aged 18 and older) paroled into the U.S. after February 24, 2022, currently live in your household? Please include yourself.

1. [dropdown – 0-10]

2. How many minor family members (aged 0-17) paroled into the U.S. after February 24, 2022 currently live in your household?

1. [dropdown – 0-10]

2. U.S. RESETTLEMENT

3. When did you arrive in the United States as a parolee?

1. [dropdown – month] [dropdown – year]

4. In what state do you currently live?

1. [dropdown list of states]

5. How well do you speak English now?

1. Not at all

2. Not well

3. Well

4. Very well

3. ASSISTANCE

6. Which of the following does your household need assistance with? Select up to three responses to help us understand needs of Ukrainian families like yours.

1. Food

2. Transportation

3. Childcare

4. Medical care

5. Mental health care

6. Employment

7. Housing

8. School enrollment

9. English language classes

10. Immigration-related legal assistance

7. Have you ever received assistance or services from a resettlement agency in your area?

1. Yes

2. No

3. I’m not sure

[If Q7 = ‘B. No’ or ‘C. I’m not sure’, continue to Q8. If Q7= ‘A. Yes’, skip Q8 and proceed to Q9.]

8. Why have you not received services from a resettlement agency? Please select all that apply.

1. I do not need assistance from a resettlement agency

2. I do not know what services I am eligible to receive

3. I do not know where to find assistance

4. The resettlement agency was not able to provide the assistance that I need

4. U.S. SUPPORTERS

9. About how often are you in contact with your U.S.-located supporter (the supporter listed on your I-134 form)?

1. Once a day

2. Once a week

3. Once a month

4. Less than once a month

5. Never

10. What kind of assistance do you currently receive from your U.S.-located supporter (the supporter listed on your I-134 form)? Please select all responses that apply.

1. Housing (i.e., I live with my U.S.-located supporter)

2. Rental assistance (i.e., My U.S.-located supporter pays for some or all of my housing costs)

3. Cash assistance to meet other basic needs

4. Donations to meet basic needs (e.g., food, clothing)

5. Assistance with enrolling in benefits or services (e.g., health insurance, English language classes, etc.)

6. Assistance with finding a job

7. Immigration assistance

8. I do not receive any assistance from my supporter

9. I used to receive some form of assistance from my U.S.-located supporter, but that assistance has ended

11. Do you expect that your U.S.-located supporter will be able to continue providing any assistance to you over the next 12 months?

1. Yes

2. No

3. I don’t know

5. BASIC NEEDS

12. What best describes your current housing situation?

1. I currently live in temporary housing such as a hotel, Airbnb, or other temporary home

2. I currently live in a house or apartment with my U.S.-located supporter

3. I currently live in a house or apartment separate from my U.S.-located supporter

4. I am currently unhoused, experiencing homelessness, or live in a shelter

E. Other housing arrangement

[If Q12 = ‘A. I currently live in temporary housing such as a hotel, Airbnb, shelter, or other temporary home’, ‘B. I currently live in a house or apartment with my U.S.-located supporter’, ‘C. I currently live in a house or apartment separate from my U.S.-located supporter’, or ‘E. Other housing arrangement’ continue to Q13. If Q12= ‘D. I am currently unhoused, experiencing homelessness, or live in a shelter’ skip Q13 and continue to Q14.]

13. Were you able to pay your housing expenses (i.e., rent or mortgage) last month?

A. Yes

B. No

C. I do not know

14. Were you able to pay for your essential living expenses (e.g., food, utilities, medical costs, basic needs) last month?

A. Yes

B. No

C. I do not know

15. How will you pay for your housing and essential living expenses in the long term (in the next 12 months)? Mark all that apply. [OPTION TO SELECT MULTIPLE]

1. Employment income from myself or immediate family members

2. Housing provided by my U.S.-located supporter

3. Financial support from my U.S.-located supporter

4. Federal or state assistance programs (i.e., rental assistance programs, Section 8 housing vouchers, Supplemental Nutrition Assistance Program – SNAP, Temporary Assistance for Needy Families – TANF, Refugee Cash Assistance – RCA, etc.)

5. Other financial sources (i.e., personal savings, financial support from friends or relatives other than my U.S.-located supporter, other)

6. I do not know how I will be able to pay for my living costs in the long term

6. EMPLOYMENT

16. Are you currently employed?

1. Yes, I have a full-time job (35 hours or more per week)

2. Yes, I have a part-time job (less than 35 hours per week)

3. No, I am unemployed, but I am actively seeking a job

4. No, I am unemployed, and I am not actively seeking a job

[If Q16= ‘C. No, but I am actively seeking a job’, continue to Q17. If Q16= any other response, skip Q17 and continue to Q18.]

17. What challenges have you faced in finding a job? Please select all answers that apply.

1. I lack employment authorization or other needed documents

2. Childcare or family responsibilities

3. Limited English language skills

4. I do not know how to find a job

5. I lack the technical skills, training, and/or credentials to qualify for jobs in my chosen field

6. Employers in my field of work do not recognize my educational degree, qualifications, or work experience from outside the US

7. Poor health or disability

8. Transportation challenges

9. Other

7. MEDICAL CARE

18. What kind of medical coverage (i.e., health insurance) do you currently have?

1. I do not have medical coverage

2. I have medical coverage through my job

3. I have medical coverage through a family member’s job

4. I have medical coverage through federal or state assistance programs (i.e., Medicaid or Refugee Medical Assistance)

5. I am not sure if I have medical coverage

[If Q18 = “A. I do not have medical coverage” or “E. I am not sure if I have medical coverage”, continue to Q19. If Q18= any other response, skip Q19 and continue to Q20.]

19. Why do you not have medical coverage? Mark all that apply. [OPTION TO SELECT MULTIPLE]

1. I do not need or want medical coverage

2. I do not know what medical coverage I may be eligible for

3. I do not know how to apply for medical coverage

4. I do not have the resources I need to apply for medical coverage (i.e., documentation, interpretation or translation, other)

5. I cannot afford medical coverage

8. MENTAL HEALTH

20. Since your arrival in the United States, have you had any problems with your work or daily life due to any emotional problems, such as feeling depressed, sad, or anxious?

1. Yes

2. No

3. I prefer not to answer

[If Q20 = “A. Yes”, continue to Q21. If Q20 = “B. No” or “C. Prefer not to answer”, skip Q21 and Q22, continue to Q23.]

21. Have you received support from a professional (e.g., consultation with a medical professional or social worker, counseling or therapy, support group) to address these issues?

1. Yes, I have received professional support

2. No, I have not received professional support

[If Q21 = “B. No, I have not received professional support”, continue to Q22. If Q21 = “A. Yes, I have received professional support”, skip Q22 and continue to Q23.]

22. Why have you not received help from a professional to address these issues?

1. I do not need and/or want professional support

2. I do not know how to access professional support

3. I cannot afford professional support

9. IMMIGRATION STATUS

23. Since you arrived in the United States, did you apply to adjust your immigration status?

    1. Yes, I applied to adjust my immigration status.

    2. No, but I plan to apply to adjust my immigration status.

    3. No, and I do not plan to apply to adjust my immigration status.

    4. I don’t know if I have applied to adjust my immigration status.

    5. I prefer not to answer

[END SURVEY]

Thank you for your time in participating in this survey.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to inform ORR program decisions to better serve the U4U Ukrainian parolees. Public reporting burden for this collection of information is estimated to average 10 minutes per respondent, including any time you needed to collect information to be able to answer our questions. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0531 and the expiration date is 9/30/2025. If you have any comments on this collection of information, please contact: [email protected].