Tropical Storm Imelda Needs Assessment Form
RequiredRequired Question(s)
Required 1.
Primary Household Information

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Please complete if your home was damaged by Tropical Storm Imelda.

This is a assessment to understand the needs, not an application for assistance. 
 
Impact of Disaster on Household
 
2.

Do you need assistance with mucking & gutting?

 

50 characters left.
Required 3.
Was your home directly damaged by Tropical Storm Imelda? (Please do not consider pre-existing maintenance issues or damage form other storms)
Yes
No
Required 4.
Were you affected by Tropical Storm Imelda other ways? (loss of transportation, sustained injury, 
 

50 characters left.
Required 5.
Please describe your living situation.
I am a renter
I am a homeowner
Other
Required 6.
Which of the following best describes your residence.
Single family home
Apartment
Mobile Home
Duplex
Condo
Townhouse
Required 7.
Do you have insurance? Please check all that apply.
Flood Insurance
Homeowners Insurance
No, I do not have floor or homeowner's insurance
Required 8.
Was the residence where you live today damaged in any previous storms? Please check all that apply.
Hurricane Harvey (2017)
Tax Day Floods (2016)
No previous damage
Required 9.
Number of people in the household?
 

50 characters left.
Required 10.
Is there a household member over the age of 65?
Yes
No
Required 11.
Does the household have children under the age of 18?
Yes
No
Required 12.
Is there someone disabled or special needs in the household?
 

50 characters left.
Required 13.
Are any members of the household a veteran?
Yes
No
Required 14.

English is not the primary language in the household.

Yes
No
  • Comment:

  • 500 characters left.
Required 15.

Is the household displaced?

Yes
No
  • Comment:

  • 500 characters left.