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The purpose of this survey is to establish a baseline for needs in our community so we can better inform you of available services and supplies as they become available.

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* 1. Name of Organization

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* 2. Contact Name

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* 3. Contact number

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* 4. What level of need are you seeing in the community for the following:

  No need Some need Lots of need
Client support for rent
Client support for water bills
Client support for gas
Client support for prescriptions
Client support for internet
Client support for phone bills
Client support for child care assistance

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* 5. What level of need are you seeing in the community for the following requests from clients:

  No need Some need Lots of need
Hand Sanitizer
Masks
Diapers
Baby wipes
Baby formula
Food
Laundry soap
Body soap/shampoo/deodorant/hand soap
Paper products - paper towels/toilet paper
Cleaning supplies

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* 6. Is your organization supplying clients with any of the items above?

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* 7. If yes, what items? 

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* 8. Please briefly explain the services your organization is providing to clients.

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* 9. In what counties does your organization provide services? (check all that apply)

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