COVID-19 Emergency Response Fund Report
Please complete this form to report the specific impact made as a result of using dollars from the County United Way, Inc. COVID-19 Emergency Response Fund. NOTE: IT IS IMPORTANT THAT INDIVIDUALS AND/OR HOUSEHOLDS ARE NOT DUPLICATED.
Organization *
Contact Name *
Email *
Amount Received *
Date Received *
MM
/
DD
/
YYYY
County for Grant *
Required
Breakdown of Grant per County
Skip if not applicable. If you received dollars that were split among more than one county, please indicate that here.
Nature of Award/Purpose *
Will you report numbers by individuals or households? *
We cannot accept a report that duplicates numbers and it must be made clear whether you are tracking/reporting the use of these dollars by numbers of individuals or number of households. This will help us tremendously in sharing data with our funders and the community. Please note that it will be expected that any additional reporting for this same grant will require the use of the same tool.
# of individuals (or households) supported *
This is the total number served. Please break down the use of funds in the next few questions. The totals below should be equal to the number here if the grant covered any of the categories that follow. PLEASE NOTE: THIS RESPONSE SHOULD BE INCLUSIVE OF ONLY THE PORTION OF INDIVIDUALS SERVED USING THESE FUNDS. Ex: $500 grant purchased 200 meals. IF THESE DOLLARS WERE SUPPLEMENTAL TO OTHER FUNDS FOR THE SAME PURPOSE, DO NOT INCLUDE THOSE FUNDS IN THIS REPORT - ONLY THE UW DOLLARS.
Cost to serve each individual or household
Above you noted the number of individuals or households served. Please list here the cost to serve each individual or household. Example: 4.55 - it is preferred that this format is used to ease our collection of information.
Have all dollars been expended?
If you answered NO to the previous question, please explain.
# of health supplies/kits
# of people or households that received food assistance
# of meals served (either by person or household)
# of food vouchers distributed (either by person or household)
# of non-food vouchers distributed (either by person or household)
# of households that received rent/mortgage assistance
# of utility bills paid
# of households that received child care assistance
# of children (collective total)
If you answered the question above for number of households, please break down the number of children served in total here.
# of individuals assisted with medical bills
# of individuals or households not included in categories above
If the number of individuals or households were not served by a category above, please list those details here.
What other types of needs have you responded to related to COVID-19 and have you had funds available to address them?
Do you have a community update or stories related to the use of these funds?
Can we share this update or story publicly?
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