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Survey-COVID-19 Community Leadership Summit
Please fill out this brief form to better help us understand the needs and capacity of potential collaborators and partner organizations.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Job Title/Position
Your answer
Organization's Name
Your answer
Describe your organization:
Faith-based/placed organization
Federally Qualified Health Center (FQHC)
Private practice/clinic
Service organization, Community based organization/agency (CBO/CBA)
Health department
Academic institution
Other:
Clear selection
What zip code is your organization located?
*
Your answer
What service(s) does your organization provide in general and during the COVID-19 pandemic?
*
COVID-19 testing
COVID-19 on-site vaccinations (e.g., able to vaccinate at agency's own location regularly)
COVID-19 mobile vaccinations (e.g., use of a van/car to support to conduct vaccinations in the field)
COVID-19 "pop-up site" (e.g., sporadic vaccination event, locations may vary)
COVID-19 education
Food assistance (e.g., grocery & meal deliveries and food pantries)
Housing assistance/vouchers
Non-COVID-19 clinical health services
Emergency financial assistance (e.g., cash assistance)
Cash/vouchers for childcare services
Mental health services
Substance use services
Legal services (e.g. debt collection, bankruptcy, and eviction protection)
Immigration services (e.g., legal, USCIS navigation assistance)
Education (e.g., books, school supplies, and assistance with virtual education)
Employment (e.g., job placement support, apprenticeship, and workforce development)
Adoption services (e.g., information on adoption and adoption agency services)
Voter registration and voting services (e.g., canvassing, transportation to polls, and voter registration)
Language translation services (e.g., staff who are multi/bilingual)
Transitional housing or residential care facilities for adults
Children's residential programs (e.g., crisis nursery, foster family agency, and Short-Term Residential Therapeutic Program (STRTP)
Other:
Required
Is there any information you would you like to learn about at this summit?
*
Vaccinations distribution (e.g., how to conduct a vaccine pop-up site)
Volunteer coordination at COVID-19 vaccine sites
Learning about COVID-19 vaccine trials in communities of color
COVID-19 vaccine education resources
Accessing vaccine allotment
Other:
Required
Please share any questions you would like the speakers to address:
*
Your answer
Please indicate language needs of clients in your organization?
*
English
Spanish
Korean
Chinese
Tagalog
Armenian
Farsi
Japanese
Russian
Vietnamese
Other:
Required
Would you need translation services for clients during a COVID-19 education or vaccination event?
*
Yes
No
Other:
What is your organization's area of focus (e.g., one sentence mission)?
*
Your answer
Would you like to sign up for the COVID-19 information listserv to stay updated on resources? (Email provided above will be used for future contact.)
*
Yes
No
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