Household Disaster Assessment Form

Household Disaster Assessment Form
Use this form to assess household disaster impact, urgent needs, and recovery priorities.
Household and Location Details
Household Primary Contact Name
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address or Disaster-Affected Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Number of Household Members
Preferred Contact Method
Disaster and Impact Assessment
Type of Disaster
Other
Date and Time of Incident
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Current Residence Status
Other
Property Damage Severity

1
2
3
4
5
6
7
8
9
10
1 is No damage, 10 is Severe damage
Injury or Medical Need Status for Household Members
Other
Utility Status
Rows Working Outage Unknown
Electricity
Water
Gas
Internet
Immediate Assistance Needed
Other
Recovery and Follow-up
Most Urgent Household Concern
Priority for Follow-up Support
Additional Notes or Access Instructions for Responders
Should be Empty:

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