EmailMe Form - Gerritsen Beach Hurricane Sandy Needs Assessment

Name *

First Last

House Number *

Street Name *

Phone *

### - ### - ####

Please provide the best number to reach you

Alternate Phone Number

### - ### - ####

Age *

Email address

How long have you lived in the community?

Total number of people in your household *

Spouse / Partner Name & Age

Children's Name & Age

Other Household Members Name & Age

What level of your home was affected by flood? *

Basement

1st floor

Other

If other, please provide additional information, including amount of water in your home

Has the damage forced you to relocate? *

Yes

No

We have no place to go

Do you need a place to live? *

Yes

No

If yes, where would you consider living if these options become available? (We do not know if any of these options are or will become available.)

How many cars were destroyed by the flood? *

Please enter a number - 0 if none

What did your family lose from the flood? *

Have you registered with FEMA? *

Yes

No

Have you signed up for NY Rapid Repairs? *

Yes

No

If no, why not?

Do you have Flood Insurance? *

Yes

No

Have you had an assessment from Homeowner's Insurance? *

Yes

No

Does your home require an assessment for structural damage? *

Yes

No

Has your power been restored by ConEd? *

Yes

No

Partially

Do you require a Licensed Electrician? *

Yes

No

Was your boiler / furnace damaged? *

Yes, Boiler

Yes, Furnace

No

Is the heating system in your house currently working? *

Yes

No

Was your hot water heater damaged? *

Yes

No

Already replaced / repaired & working

Do you require a visit from a Licensed Plumber? *

Yes

No

Are you having a problem with mold? *

Yes

No

Do you need volunteers to help with sheetrock demolition or debris removal? *

Yes

No

Already completed by volunteers

If yes, please explain your circumstances and needs

Are you handicapped/disabled or have a medical condition? *

Yes

No

Are you able to leave your home? *

Yes

No

If no, explain why and what type of assistance could help you

Would you like to be visited by or meet with counselors from the Red Cross or other agencies? *

Yes

No

Do you have pets? *

Yes

No

How many dogs?

How many cats?

How many other pets?

Do you feel you were overcharged by any contractors? *

Yes

No

If yes, by whom? Please include contact info

Do you think you will return to your home and community? *

Yes

No

Unsure

Please provide any additional information we may have missed.