Coronavirus (COVID-19) Cooperative Relief Assessment Form
RequiredRequired Question(s)
Required 1.
Contact for Cooperative 

First Name:
Last Name:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Required 2.

Business/ Co-op Name 

 

50 characters left.
Required 3.

 Is this cooperative a member of the Federation?

Yes
No
Required 4.

Gross Revenues for the Twelve (12) Month Prior year (2019)

0-10,000
10,000-50,000
50,000-100,000
100,000-150,000
150,000 or more
  • Comment:

  • 500 characters left.
Required 5.

Please describe your cooperative operation. Be sure to include the following: 

Crops grown
Number of Animals 
Number of Members 
Number of Employees 
 

350 characters left.
Required 6.

Are your markets affected COVID-19 ( such as farmers markets, schools, restaurants, etc.)?

Yes
No
  • Comment:

  • 500 characters left.
Required 7.
Briefly describe the impact the Coronavirus is having on your cooperative.
SELECT ALL THAT APPLY
Reduced markets to sell your products (restaurant sales down, farmers markets closing, etc.)
Reduced income due to loss of, or limited, off-farm work
Added healthcare costs
Lack of resource availability due to other business closures (e.g. seed companies, mechanics, delivery services, etc.)
Lack of ability to retain employees and or members due to decreases in your business income
Inability to complete planned projects (infrastructure or otherwise) due to disrupted supply chains
Additional care-taking responsibilities that limit the time on your farm (i.e. childcare needs due to school closures, caretaking for other family members, etc.)
Other  
  • Comment:

  • 500 characters left.
Required 8.
What resources does your coop most need?
SELECT ALL THAT APPLY
Direct financial assistance
Accounting/ business planning help
Food safety response planning assistance
Access to mental health care
Social/ digital media assistance for communicating with customers
Software and other technological support
Help connecting to others in your community
Help getting customers to purchase food you have for sale now
Other  
  • Comment:

  • 500 characters left.
Required 9.

What other resources would be helpful? 
SELECT ALL THAT APPLY 

Policy advocacy and support around this issues and related needs
Web-based community meetings to discuss shared challenges and solutions
A list of financial resources
Other  
  • Comment:

  • 500 characters left.
Required 10.

Has your cooperative applied for any available disaster aid?

If yes, please list

Yes
No
  • Comment:

  • 500 characters left.
Required 11.
Is your cooperative seeking disaster relief funds due to COVID-19? 


Yes
No
12.


If you answered yes to the previous question, please provide your lead contact information for our disaster assistance program:

Please list their ( Name, Title , Phone Number and Email Address ) in the text box below.


 

50 characters left.