Health New England's COVID-19 Response Fund Submission Form
Organization Name:
Organization Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Point of Contact's Full Name:
First Name
Last Name
Point of Contact's Title:
Point of Contact's Email:
example@example.com
Point of Contact's Phone Number:
-
Area Code
Phone Number
Program or Initiative Name:
Most Programs Are From A – B Timeline and Not One Program Date(s):
Enter in Program Start and End Date
Dollar Amount Being Requested:
Please Describe The Program or Initiative You Will Be Implementing To Support Vulnerable Communities That Are Impacted By COVID-19 Crisis?
Priority Populations Your Program Focuses On (Please Choose All That Apply):
Children and Youth
Communities of Color, particularly Latinx and Blacks
Individuals Living in Poverty or with Low Income Levels
Elderly Adults
Individuals with Underlying Health Conditions
Undeserved Communities
Select The Following Health New England COVID-19 Health Priorities And Other Health Factors That Your Program or Initiative Will Improve (Check All That Apply):
Access to Healthy Foods
Child Care
Chronic Conditions
COVID-19 Vaccine Education and Outreach
Digital Divide
Education
Housing Needs
Lack of Resources to Meet Basic Needs
Mental Health and Substance Use
Pediatric/Adolescent Isolation and Anxiety Due to COVID
Preventive health (i.e. Physical Activity & Nutrition)
Social Determinants of Health:
Built Environment (includes Transportation, Access to Healthy Foods)
Education
Employment
Housing
Social Environment (Social Isolation, Institutional Racism)
Violence and trama
Estimated Reach/Anticipated Number of Lives Program will Touch:
Please Describe How You Will Evaluate The Success Of The Program Or Initiative. Include A Description Of What Success Will Look Like:
Geographic Area Served (Choose all That Apply):
Berkshire
Franklin
Hampden
Hampshire
Worcester
Other
Are You Currently a Health New England Employer Group?
Yes
No
Submit
Should be Empty: