PPE Needs Survey for People with Disabilities
1. Contact Info
2. Of the following choices, how do you identify?
Person with a disability
Older New Yorker
Both a person with disabilities and an older New Yorker
3. Who are you requesting face covering for?
4. How many face coverings are you requesting? (up to 1 , 2 , or 3 masks per request)
5. This form is intended for individuals with disabilities who meet all of the following criteria as a result of the COVID-19 emergency. Do you confirm the following?
No members of the household can go out and get PPE masks for you because they are at increased medical risk or homebound.
No neighbors or family members can go out and get PPE masks for you.
You are not connected to providers or nonprofit agencies who can mail or deliver PPEs to you.
You are unable to afford to purchase PPE masks.