Black Hawk County COVID-19 Childcare Response Team - Assessment of Childcare Need
Schools, community organizations, and employers are mobilizing to support our important medical personnel and first responders, to ensure our healthcare system is strong and able to respond to the emerging issue of COVID-19.  

The purpose of this form is to identify the current and anticipated childcare needs of ESSENTIAL PERSONNEL, which includes hospital staff, healthcare providers, direct care staff (i.e. nursing homes, etc), government personnel essential to infrastructure (public safety, public health, child protection services, etc), emergency responders, and employees in food supply (grocery, restaurant, etc). If you currently have or believe you could have childcare needs in the coming weeks, please fill out the information below.

Please consider this an initial intake that will help us evaluate the need and determine how to connect needs with the resources we have available in our community.
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Name (first and last)
Contact Phone Number
Contact Email (we will not use your email for anything other than contacting you regarding childcare services related to COVID-19)
Town/City (will be used in an effort to match closest childcare resources to families)
Employer
Job Title/Role - Please describe the nature of your position. Be as descriptive as possible.
As we work to prioritize needs, do you believe your role is essential to the well-being and health of the community (health care, care of elderly/vulnerable populations, public safety, and food supply)?
Clear selection
Additional comments or explanation on the previous question:
What has been your regular current childcare arrangement?
Clear selection
Is your current childcare still open/available?
Clear selection
Do you believe your current childcare may close or become unavailable?
Clear selection
Do you have back-up childcare options already identified and/or arranged?
Clear selection
If you anticipate needing alternate care, please indicate the arrangement(s) you would prefer:
For how many children are you seeking childcare assistance?
Please list the ages of your children for whom you are seeking care:
Days you will need care (check all that apply):
Timeframe for care (check all that may be needed):
Do you anticipate a need for overnight care?
Clear selection
Does your child(ren) require any supports (special needs, health care needs, etc.) we should be aware of?
Please keep me informed via email of childcare options available.
Clear selection
If you have additional comments or information, or if you would like to explain any of your answers above, please do so here.
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