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Jefferson County COVID-19 Resources Questionnaire
This form has been modified since it was saved. Please review all fields before submitting.
What services are you offering? What distribution method is being used?
Contact Email Address
Contact Phone Number
Hours of Operation
What are the primary populations that your organizations serves that may be disproportionately impacted by the COVID-19 crisis?
Communities of Color
Incarcerated or detained populations
Individuals experiencing homelessness
Individuals experiencing domestic violence
Individuals with disabilities
Populations experiencing hunger, food, or nutrition insecurity
Mountain community populations
Children under 18
People whose native language is not English or with low English language proficiency
Do you provide any services in languages other than English? If so, which services and in what languages are they provided?
Are walk-ins accepted or do you need an appointment?
Walk-ins accepted but appointment is preferred
Is this service free or at cost? Please include cost in your answer.
What supplies or material resources does your organization need?
Cardboard boxes/bags for distribution
Safety Supplies (disinfectant, gloves, etc.)
Any other information you would like us to know?
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