The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value you provided must be within the suggested range

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Required format:

8ggIsEEfPFvJgZB2v5BUcMEWEcIahytfD

COVID-19 Pandemic Food Response - Request Form

Thank you for your efforts to support MUSC Care Team Members. This quick survey allows you to identify a unit/department for food support services. You may also use this form to identify yourself as someone in need of food assistance or support.

The COVID-19 pandemic is a tremendous stressor for MUSC Care Team Members and their families. Many of our Care Team Members are experiencing financial and/or food insecurity as a result of a reduction in hours, temporary layoffs and increased household expenses related to the pandemic.

In this time of need, we seek to provide resources directly to our MUSC Care Team Members and want to provide managers, colleagues and all members of our MUSC family with the opportunity to provide support wherever they see a need.

This form allows for any MUSC Care Team Member to identify a unit/larger team to receive support in the way of a free meal, groceries, or a catered meal free of charge in an effort to provide support and alleviate the burden that so many are currently facing within our own organization.

This form can also be used for individuals to identify their need for food support.

We will accommodate as many incoming requests as possible.

Nominators have the option to remain anonymous.

I would like to remain anonymous

* must provide value

yes

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Salutation

First Name

Last Name

Suffix

Department or Unit

Phone Number

Who would you like to nominate?

* must provide value

a unit or department

yourself as an individual

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Care Team Member's full name

* must provide value

Care Team Member's unit or department

* must provide value

Care Team Member's email

Care Team Member's phone number

* must provide value

Care Team Member's mailing address

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Unit or Department Name

* must provide value

Location (campus, building, floor, etc.)

* must provide value

Is this unit located in any of the following buildings on the downtown campus:

Main/University Hospital
Ashley River Tower (ART)
Shawn Jenkins Children's Hospital (SJCH)
Rutledge Tower (RT)
Hollings Cancer Center (HCC)
Storm Eye Institute (SEI)
University Hospital Extention/Old Children's Hospital

* must provide value

Yes

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Since this unit is located within one of these buildings, we are unable to use external restaurants or caterers to provide meals.

Please let us know if your unit would be open to exploring any of the following options (select all that apply):

Care Team Members pick up donated meals from the MUSC Urban Farm

Care Team Members receive a meal ticket to use in the MUSC cafeterias

Care Team Members receive a coupon to redeem at a local restaurant or establishment

Point of contact name

* must provide value

Point of contact email

* must provide value

Point of contact phone number

What is the time range for the shift you would like to serve?

* must provide value

Approximately how many Care Team Members will we need to serve during that shift?

* must provide value

What is the drop off location for meal delivery? (e.g. nurse's station, first floor front desk, etc.)

What is the reason you are nominating this unit? Do you have any specific requests?

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Has this Care Team Member been negatively affected by the temporary layoffs?

Please note that if that's the case, we will need a physical mailing address and/or non-MUSC email in order to contact the individual.

* must provide value

Yes

reset

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

COVID-19 Pandemic Food Response - Request Form

Your Contact Information

This information is optional, however, if we have a question about your nomination, we may need to contact you for clarification.

Nominee's Information

Who would you like to nominate?

Point of Contact's Information

Reason for Nomination

You have selected an option that triggers this survey to end right now.