Emergency Support Program
1.
How do you identify?
Person with a SCI
Family member of a person with a SCI
Caregiver of a person with a SCI
Other physical disability or visual impairment
2.
First and Last Name
3.
Email
4.
Phone Number
5.
During this time, are you
safely
able to meet your daily needs in the following areas:
Yes, by myself
Yes, with help from other people (family, friends, caregiver)
Yes, with help from organizations
No
Does not apply to me
Having enough food
Yes, by myself
Yes, with help from other people (family, friends, caregiver)
Yes, with help from organizations
No
Does not apply to me
Having enough medicine
Yes, by myself
Yes, with help from other people (family, friends, caregiver)
Yes, with help from organizations
No
Does not apply to me
Getting help from caregivers
Yes, by myself
Yes, with help from other people (family, friends, caregiver)
Yes, with help from organizations
No
Does not apply to me
Service animal care
Yes, by myself
Yes, with help from other people (family, friends, caregiver)
Yes, with help from organizations
No
Does not apply to me
PPE supplies (hand-sanitizer, sanitizing wipes)
Yes, by myself
Yes, with help from other people (family, friends, caregiver)
Yes, with help from organizations
No
Does not apply to me
Medical supplies (urological, incontinence)
Yes, by myself
Yes, with help from other people (family, friends, caregiver)
Yes, with help from organizations
No
Does not apply to me
6.
Would you like to have access to online videos or resources about any of the following topics:
Exercise
Nutrition
Mindfulness
Virtual socializing (group meet ups)
7.
What would be most helpful to assist you during this time?
8.
Have you contacted any organizations for information or help during this time?
Yes
No
9.
What are you most worried about during the COVID-19 crisis? (check all that apply)
Running out of food
Running out of medicine
Running out of medical supplies
Not having the help you usually have
Overall health and well-being
Social Isoloation
Other (please specify)
10.
Anything else you would like to share?
Current Progress,
0 of 10 answered