GJMA Distro Line Questionnaire

[ Read this to the participant ]

By coming to the Mutual Aid Distro, giving your information for this form, and/or receiving the services offered you are agreeing to abide by these simple guidelines while you are here

  1. Refrain from the use or sale of drugs on the distro premises and the adjacent properties within 4 blocks
  2. Please do not stay at the UU or our neighbor’s buildings after the distro is complete at 1pm
  3. Do not be disruptive, we reserve the right to ask you to leave
  4. Wear a mask at all times while at the distro
  5. Take only what you need until your next pickup
  6. Only volunteers are allowed inside the UU building

  • initials are acceptable
  • Hidden
  • Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea.
  • (within 6 ft for 15 minutes)
  • Optional

    (open ended question- allow participant to self identify):
  • Check all that apply
  • Make any important notes for this client