Recovery Needs Assessment Form

Recovery Needs Assessment Form
Please complete this form to help us understand your recovery needs following a recent emergency or disaster.
Full Name
First NameLast Name
Contact Information (Phone Number)
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
How many people are in your household (including yourself)?
Household Members and Special Needs
Rows Age Group Disability or Special Need
Person 1 1
Person 2 2
Person 3 3
Person 4 4
Person 5 5
Please rate the extent of damage to your home.

1
2
3
4
5
1 is No Damage, 5 is Completely Destroyed
What are your most urgent needs right now?
Other
Please rate your current access to the following resources.
Rows No Access Limited Access Adequate Access
Food
Water
Electricity
Medical Care
Communication
Transport
Have you received any assistance since the event?
If yes, please specify the type of assistance received.
Other
What are the main barriers preventing your recovery?
Other
Please provide any additional comments or urgent needs.
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