Veterans Emergency Management Evaluation Intake Form
Please provide information about your experience with emergency management services. Your feedback will help us improve support for veterans during emergencies.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a veteran?
*
Yes
No
Branch of Service
Please Select
Army
Navy
Air Force
Marines
Coast Guard
Other
Date of Emergency Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Emergency Incident (City, State)
*
Please select the type of emergency you experienced.
*
Please Select
Natural Disaster (e.g., hurricane, flood, wildfire)
Medical Emergency
Accident
Evacuation
Other
Please rate the following aspects of the emergency management services you received.
*
Rows
Excellent
Good
Fair
Poor
Timeliness of response
1
2
3
4
Professionalism of staff
5
6
7
8
Effectiveness of assistance
9
10
11
12
Communication and updates
13
14
15
16
What assistance did you require during the emergency? (Select all that apply)
*
Shelter
Medical assistance
Food/Water
Transportation
Emotional support
Other
Did you receive the assistance you needed?
*
Yes
No
Please provide any additional comments or suggestions for improving emergency management services for veterans.
Submit Evaluation
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