COVID-19 (Coronavirus) Needs Assessment
UPDATE: AS OF MONDAY JUNE 15, WE ARE LONGER SCHEDULING NEW DELIVERIES OF COVID-19 RELIEF PACKAGES.
We will fulfill qualified requests up to this date. Due to the high volume of responses deliveries are delayed.
Review the instructions below before getting started:
1 You can still use this form to be connected to partners for help with SNAP/cash assistance, home food delivery, health services, senior and caregiver support, and many other direct services. We will also do our best to connect you to other neighborhood-based resources.
2. Please provide full contact information. We cannot redirect you to resources without having this information.
3. In order to qualify, you must live in one of the 17 participating NYCHA developments. If you do not live in any of the listed NYCHA developments but choose to fill out the form anyway, we will do our best to forward your information to partners who can assist you with your needs.
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We are honored to serve and support you. We’re all in this together! Let’s keep each other safe and healthy!
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I do not live in any of the NYCHA developments listed.
Do you have any pre-existing medical conditions?
Pre-existing conditions, include: Asthma, Hyper Tension, Diabetes, Lung Disease, Cancer or Auto Immune Disease. This question will help us determine if you need a delivery made to your door.
Check all that apply:
This question will help us determine if you need a delivery made to your door.
I have trouble standing for long periods of time.
I have trouble walking without a crane, walker, wheelchair or other support.
I cannot carry 25lbs or more.
None of the above
Are you experiencing a food shortage?
Do you have any allergies or dietary restrictions?
Are you experiencing a shortage of cleaning supplies?
Do you need masks and gloves?
Do you need any personal hygiene supplies?
Are you concerned about having access to clean drinking water?
Do you need help accessing necessary medication?
Do you have access to the internet?
I do have access to the following technology:
(Check all that apply)
Are you concerned that you may have been exposed to the Coronavirus/COVID19?
Do you need to work with a specialist 1-on-1 to connect to more resources?
If you're a MAP resident, you have access to additional assistance from groups like HRA (SNAP and Cash Assistance), DFTA (Senior & Caregiver Support), and more. Let us know if you'd like us to follow up with you about these resources.
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This form was created inside of Center for Court Innovation.