Lockdown Impacts on Family Wellbeing
This form is to collect data for the Wellbeing team at NZTSOS to compile a report on the effects of the Lockdowns and Mandates on family wellbeing. The form is confidential and no names, or other identifying data are required. The data will be used as evidence in court proceedings in 2022 against the Government.

Please complete this form by the 28th of January. Thank you so much for your help.

Sign in to Google to save your progress. Learn more
1.  Lockdowns: Has your child/children or young person/s been affected by being in lockdown?
1a) If yes to Q1, in what way has their Physical Health been affected?  
Negative Impact
Positive Impact
Clear selection
1b) If yes to Q1, in what way has their Mental health been affected?  
Negative Impact
Positive Impact
Clear selection
1c) If yes to Q1, in what way has their Social wellbeing been affected?  
Negative Impact
Positive Impact
Clear selection
1d) If yes to Q1, in what way has their Mood been affected?  
Negative Impact
Positive Impact
Clear selection
1e) If yes to Q1, in what way has their overall Wellbeing been affected?  
Negative Impact
Positive Impact
Clear selection
1f) If yes to Q1, in what way have their whanau/family relationships been affected?  
Negative Impact
Positive Impact
Clear selection
1g) If yes to Q1, in what way has their economic security been affected?  
Negative Impact
Positive Impact
Clear selection
1h) Please add any comments to any of the questions above to expand on your situation.
Q2 Mental Health:  Are you concerned about your children's Mental health?
2a) If yes to Q2, are you concerned about Depression?
Very Concerned
Not Concerned at all
Clear selection
2b) If yes to Q2, are you concerned about Self-harm?
Very Concerned
Not Concerned at all
Clear selection
2c) If yes to Q2, are you concerned about Suicidal ideation?
Very Concerned
Not Concerned at all
Clear selection
2d) If yes to Q2, are you concerned about Anxiety?
Very Concerned
Not Concerned at all
Clear selection
2e) If yes to Q2, are you concerned about PTSD (Post Traumatic Stress Disorder)/historical PTSD/trauma being triggered?
Very Concerned
Not Concerned at all
Clear selection
2f) If yes to Q2, are you concerned about Isolation?
Very Concerned
Not Concerned at all
Clear selection
2g) If yes to Q2, are you concerned about Bullying?
Very Concerned
Not Concerned at all
Clear selection
2h) If yes to Q2, are you concerned about Family violence?
Very Concerned
Not Concerned at all
Clear selection
2i) If yes to Q2, are you concerned about Loneliness?
Very Concerned
Not Concerned at all
Clear selection
2j) If yes to Q2, are you concerned about Abuse (sexual/ physical/ emotional/ relational)?
Very Concerned
Not Concerned at all
Clear selection
2k) If Yes to Q2j, indicate which types of abuse below.
2l) If yes to Q2, are you concerned about Eating disorders/eating disordered behaviour?
Very Concerned
Not Concerned at all
Clear selection
2m)  Please add any comments to any of the questions above to expand on your situation.
Q3) Have you needed to contact mental health services?  
Q3a) If Yes to Q3,  have you actually received services?    
Q3b) What was the actual waiting time for you to receive support from mental health services?
Q3c) Comment if necessary, for question 3a) (for example, if you have had to pay for a private provider due to long waitlists etc.)
Q4) Have lockdowns and the mandates have a negative impact on your families wellbeing in general?    
Q4a) Comment if nessary, for question 4)
Q5) Have lockdowns and the mandates have a negative impact on your family/whanau relationships?    
Q5a) Comment if nessary, for question 5)
Q6) Have lockdowns and the mandates had a negative impact on your spiritual / cultural wellbeing?  
Q6a) Comment if nessary, for question 6)
Q7) Do you have any other comments on how the lockdowns have affected yourself or your family which the questions above have not covered?
Q8)Vaccination rollout  - Has the vaccination rollout had an impact on your and your family's wellbeing?
Q8a) In what way has their Physical Health been affected?
Negative Impact
Positive Impact
Clear selection
Q8b) In what way has their Mental health  been affected?
Negative Impact
Positive Impact
Clear selection
Q8c) In what way has their Social wellbeing been affected?
Negative Impact
Positive Impact
Clear selection
Q8d) In what way has their Mood  been affected?
Negative Impact
Positive Impact
Clear selection
Q8e) In what way has their overall Wellbeing been affected?
Negative Impact
Positive Impact
Clear selection
Q8f) In what way have their whanau/family relationships been affected?
Negative Impact
Positive Impact
Clear selection
Q8g) In what way has their economic situation been affected?
Negative Impact
Positive Impact
Clear selection
Q8h) If you wish not to get vaccinated, have you and your family felt peer pressure/pressure from others to get vaccinated?
No Pressure
Lots of Pressure
Clear selection
Q8i)  Please add any comments to any of the questions in section 8 above to expand on your situation.
Q9) Rollout  of the traffic light system - Has the traffic light rollout had an impact on your children's wellbeing?
Q9a) In what way has the traffic light system had an effect on their Physical Health ?
Negative Impact
Positive Impact
Clear selection
Q9b) In what way has the traffic light system had an effect on their Mental health?
Negative Impact
Positive Impact
Clear selection
Q9c) In what way has the traffic light system had an effect on their Social wellbeing?
Negative Impact
Positive Impact
Clear selection
Q9d) In what way has the traffic light system had an effect on their Mood ?
Negative Impact
Positive Impact
Clear selection
Q9d) In what way has the traffic light system had an effect on their overall Wellbeing?
Negative Impact
Positive Impact
Clear selection
Q9e) In what way has the traffic light system had an effect on their whanau/family relationships?
Negative Impact
Positive Impact
Clear selection
Q9f)  Please add any comments to any of the questions in section 9 above to expand on your situation.
Q10)Has your child been affected by the loss of a teacher / teacher aid/ coach / counsellor/ ECE/ dance/ gym/ swim teacher etc.
Q10a) If yes to Q10, how much has your child been affected by the loss of a teacher / teacher aid/ coach / counsellor/ ECE/ dance/ gym/ swim teacher etc
Negative Impact
Positive Impact
Clear selection
Q10b) If yes to Q10, please add more detail if you wish.
Q11) Has your family been affected personally by the no jab/ no job mandate?  
Q11a) If yes to Q11, how much impact does the no jab/ no job mandate have on your family?
Negative Impact
Positive Impact
Clear selection
Q11b) Please add any any further comment on Q11 here
Q12) Does the requirement to wear masks have an impact on your child/children's overall wellbeing?
Q12a) Please add any any further comment on Q12 here
Q13) Demographic questions- Please answer these to help us group and collate the data - Region you live in
Q14) Number of children in the family
Q15) Ages of children in your family
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy