Intake Form- COVID-19 Medical Professionals in Need of Housing
This form will help us collect information we need to aid COLORADO medical professionals (Doctors, nurses, ER techs etc.) who are in need of temporary housing due to COVID-19 quarantine, positive test result or if you are in need of housing due to immunocompromised family members. We appreciate your hard work and sacrifice keeping the rest of us safe! Please complete the form in its entirety and you will be added to our waiting list for emergency housing for front line medical professionals. Thank you so much for all that you are doing during this crisis.
We will contact you with potential temporary housing matches as soon as available. We are all in this together!!
If you are a medical professional from somewhere outside of CO please contact RVs 4 MDs (a national initiative):
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First and last name (medical professional)
Phone number where you can be reached.
Email address where you can be reached.
Profession and location of work (i.e. RN in emergency department, RT in ICU, MD on an inpatient ward, PA in long-term care facility, etc.)
Employer hospital/medical facility name
Please list county where you work and/or all counties where you would be willing to accept temporary housing.
Total number of people living in your household.
Please describe why you are applying for temporary housing (e.g. COVID-19 and don't want to infect family member at home with emphysema, work in ICU with COVID-19 patients and have child at home on chemotherapy, COVID-19 rule-out, etc).
Do you or family members have any serious medical conditions? If yes please describe.
Single family home
We have housing offers for 2-4 bedroom homes. Please clarify if you would be willing to have roomates in the temporary housing (everyone would have own bedroom). Medical professionals who are willing to have roomates must identify 1-3 coworkers with whom they would be wiling to room.
No I don't want to have roomates
I want roomates and they are listed below in comments section.
Any other recommendations/needs?
Thank you for your submission and we will be in touch shortly. Please note we will require you to upload your ID badge to verify your status as a medical professional and eligibility for housing. www.HousingCovidHeroes.org
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