COVID-19 Needs Assessment

COVID-19 Needs Assessment

for Individuals/Families
The Local Love Project
wants to help you
With the outbreak of the infectious Coronavirus disease (COVID-19), the Local Love Project is seeing a large increase in requests for help from our community and many of our Ventura County outreach and assistance organizations.

We have created the following form to track needs so that we can work effectively in our efforts to find solutions and assist where we are able.

We want you to know that our team of dedicated volunteers is here, working to help our community in this unprecedented time of need.

Please note that the Local Love Project serves the Ventura County, California community only.
Note: This form is intended for INDIVIDUALS/FAMILIES. If you are a business or organization, please click here to access the business form.
Full Name*

First NameLast Name
E-mail*
Phone Number*
(XXX) XXX-XXXX
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Currently employed?*

NoYes (please describe below)
Current employer*
Job position or description*
Laid off due to COVID-19 mandate?*

YesNo
Are you a low income household?*

YesNo
Does your household have access to a car and driver?*

YesNo
Are you or someone in your household
Disabled?

YesNo
Elderly?

YesNo
Home bound?

YesNo
Describe issues
If you have children, is their school closed due to COVID-19 mandate?*

YesNoDon't have school-aged children
What are your specific needs as they relate to the current Coronavirus (COVID-19) crisis and its impact on your household?
Financial needs
Specific item needs
Educational needs for students
Need for help from volunteers
Should be Empty: