Requisition Supplies/Materials Form

Reproductive Justice Needs Assessment

A Collabrative Community Initiative by TKO Society & Yellow Hammer Fund
For more information about The Knights & Orchids Society or Yellow Hammer Fund, please visit our website (www.tkosociety.com) or social media pages.
Name

First Name Last Name
Age
Today's Date *

Month Day Year
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Select Branch: *
Submitted By: *
Household Information
1. Number of people in the family?
2. How many Military Veterans?

3. How many of each age group is in the household?

Satisfied

0-12

13-18

19-29

30-39

40-49

50-59

60-69

70 and up

4. Please check one or more boxes below:

My household receives food stamps. My household receives SSI. My household has special circumstance. (Fire, Flood, Homeless etc.) My household is below poverty level. (unemployed, low-income, etc.) None of these apply to my household.
Are you currently employed?

Yes No

5. General Baby Items: *

Select

Sizes

Baby Formula

Infant Tylenol, gas medicine, cold and flu etc.

Nursing bras, Breast pads, Nipple cream

Breast pump & accessories

Milk freezer bags, Formula etc.

Diapers, Wipes, Pull-Ups

None

6. Please type in your request for supplies that are not included in the list above

7. Essential Items *

Select

Any thoughts?

Food bags

Elderly Underwear

Hygiene products (Pads, tampons, Summer Eve and raziers)

81 mg Aspirin

Pregnancy Test

Plan B (Day After Pill)

Condoms/Lubricant

HIV Home Test

None

YOU MADE IT!

Thanks for taking the time to submit this needs assessment for us. These assessments help us figue out which services and resources the community values and helps us better provide the things our community wants. Feel free to go back through and check your answers or you can hit submit now.
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Reproductive Justice Needs Assessment