ESUC Resources and Needs Survey

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Serving you and our community during COVID-19

Name *

Full name or family name

Email Address *

Primary Phone Number

Home Address

Assessment of Communication

Check all that apply

I have internet at home on a computer

I have internet at home on a smart phone

I am accessing internet outside of my home

Other:

Assessment of Your Situation

Check all that apply

I am well and healthy at this time

I know how to access pastoral care when I need it

I am well but cannot afford to keep two weeks of groceries stocked at home

I am ill with COVID-19 (or what I suspect could be COVID-19)

I have another serious health condition or illness

I am hospitalized

I am ill and unable to prepare (or go out to eat) my own meals

I am ill and in need of childcare, elder or dependent care, or respite care

I am ill and in need of help with pet care

Someone I live with is ill with COVID-19 (or what I suspect could be COVID-19)

Someone I live with has another serious health condition or illness

Other:

Resources

Check all the ways you're available to help fellow congregants and church leaders

Calling folks who are isolated

Grocery shopping for folks who are unable to get out

Preparing meals for people who are ill

Delivering meals to people who are ill

Helping folks learn how to get on Zoom (by calling and walking them through the process)

Caring for pets (in my own home) of people who are ill

Contributing to the Ministers' Emergency Fund, to help those who are struggling (even a small donation helps)

I'm a health care professional and can answer questions in Zoom gatherings online

I'm a mental health professional and can help facilitate Zoom gatherings online

I've been trained as a small group leader and can help facilitate Zoom gatherings online

Other:

Needs

Check the kinds of help you currently need from church

Help learning how to use technology like Zoom, so I can attend church gatherings online

Phone calls to keep me connected as I practice social distancing or am quarantined

Grocery shopping

Meal delivery

Financial help

Opportunity to get my questions about COVID-19 answered

I don't have a safety net of friends/family nearby; please check in with me

Other:

I have filled out this form before. This is an update to my previous submission. *

Yes

Is there anything else you want us to know?

Submit

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