Request 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. Technical assistance is provided in alignment with the mission of the Erie County Office of Health Equity. All technical assistance is free. Assistance is prioritized based on relevance to the Erie County Health Equity Act of 2021, upcoming 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

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

Yes

I’m not sure

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