Request Grant Technical Assistance From the Erie County Office of Health Equity

Use this form to request grant related technical assistance from the Erie County Department of Health Office of Health Equity for your group or organization. Grant technical assistance is provided in alignment with the mission of the Erie County Office of Health Equity. All grant-related technical assistance is free. Grant assistance is prioritized based on relevance to the Erie County Health Equity Act of 2021, upcoming application deadlines (if any), and an organization’s capacity and resources, including staff, funding, and experience. For assistance with an active grant application, this form must be submitted at least two weeks before the grant deadline.

Fields marked with an asterisk (*) are required.

Name of group or organization

Address

Address 2

City/Town

State

ZIP Code

First name of contact person

Last name of contact person

Confirm email

Phone number

How would you prefer to be contacted?

Phone

Can we add you to the Office of Health Equity email list?

Yes

Does your organization serve Erie County, NY?

Yes

Type of group/organization. (check all that apply)

501(c)(3) non-profit organization

Block club

Community center

Community-based organization

Faith-based organization/group

Grassroots organization

Non-profit organization

Other…

What is the mission or goal of your organization or group?

Does your organization work in a particular area (neighborhood, city, etc.) or with a certain community (farmers, immigrants, the LGBTQ+ community, older adults, the Black/African American community, people with disabilities, etc.)? Please specify.

How many people work or volunteer at your organization or group (including you)?

1-5

6-10

11-20

21-50

51+

I’m not sure

What is your organization or group's annual budget?

Less than $500,000 per year

$500,000 to $1 million per year

More than $1 million per year

My organization or group does not have an annual budget

I’m not sure

Have you received grant assistance from the Erie County Office of Health Equity before?

Yes

I’m not sure

What grant experience does your group or organization have? (check all that apply)

We have applied for grant funding in the past

We have received grant funding in the past

We currently receive funding from at least one grant

We have had someone who helps with grants in the past, but do not have anyone who helps with grants right now

We currently have a staff person or volunteer who applies for/coordinates our grants

None of these

I’m not sure

Other…

What kinds of assistance are you looking for? (check all that apply)

Help finding grants

Help applying for grants

Help with data and evaluation

Help with grant reporting

Other…

Are you applying for a grant right now, or have you found a grant you would like to apply for soon?

Yes

I'm not sure

When is the grant application due? If you are applying for more than one grant, enter the deadline that is the soonest.