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2021 Winter Storm Needs Assessment
Please fill out this 10 min. survey to share your needs with local non-profits. Your participation will allow us to advocate for more resources for our community and strengthen recovery efforts. This isn’t an application for assistance, but you can opt-in to receive text messages about new resources as they become available.
The personal information you enter on this survey will not be shared with government agencies.
Respondent Information
Are you filling out this survey on behalf of someone else?
Yes
No
If you are filling out this survey out on behalf of someone else, please select the option that best describes you:
Please select...
Family member
Friend
Neighbor
Volunteer/Nonprofit
Please select the name of the organization you represent or are volunteering with:
Please select...
AmeriCorps
Avenue CDC
BakerRipley
Catholic Charities
Fifth Ward CRC
Hope Disaster Recovery
Houston Food Bank
Houston Habitat for Humanity
Houston Responds
Houston Volunteer Lawyers
Jewish Family Service
Katy Responds
Lone Star Legal Aid
Rebuilding Together Houston
Red Cross
Salvation Army
SBP
St. Vincent DePaul
Team Rubicon
Tejano Center
The Restoration Team
United Way of Greater Houston
Volunteer Houston
West Street Recovery
Other
Please write the name of the organization or group you represent or are volunteering with:
How did you hear about the 2021 Winter Storm Survey?
Please select...
Nonprofit or faith-based organization
Friend, family, or neighbor
Web search
211
Social Media
T.V.
Newspaper or other print media
Recovery Center
Government agency
Other
If you selected 'Other', please specify where you heard about this survey:
If you were referred to the 2021 Winter Storm Survey by a non-profit or faith-based organization, please type the name of that organization:
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Impact of the 2021 Winter Storm on the Household
Living Situation
What was your living situation before the Winter Storm hit?
I was a renter
I was a homeowner
I was homeless (I was staying in a hotel, shelter, family/friend's home temporarily prior to the 2021 Winter Storm)
Other
If you selected "Other", please provide detail here:
Which of the following best describes where you lived before the Winter Storm hit?
Single-family home
Apartment
Mobile home
Duplex/fourplex
Condo
Townhome
When was the home built?
Before 1960
1960 - 1980
1981 - 2000
After 2000
Not sure
What types of insurance do you have? Please check all that apply:
Flood insurance
Homeowners insurance
Renters insurance
None of these
Was the residence where you live today damaged in any previous storms? Please check all that apply:
Tropical Storm Imelda (2019)
Hurricane Harvey (2017)
Tax Day Floods (2016)
Memorial Day Floods (2015)
Hurricane Ike (2008)
Tropical Storm Allison (2001)
It was not affected in previous storms
I do not know if it was affected in previous storms
Did you lose power as a result of the Winter Storm?
Yes
No
For approximately how many hours was your home without power (24 hours in a day)?
Less than 12 hours
12-24 hours
2 days
3 days
4+ days
Home Damage
Was your home damaged
directly
by the 2021 Winter Storm?
Yes
No
We're very sorry to hear that. Make sure to take as many pictures of the damage as possible. Taking pictures will be useful in proving losses to FEMA, your insurance company, and for other relief agencies should assistance become available.
We will have resources for you on how to apply for assistance after you submit the survey.
Will your insurance cover the damages from the Winter Storm?
Yes
No
I'm not sure
If you have insurance, can you afford your deductible?
Yes
No
I'm not sure
How was your home damaged? Please check all that apply:
Pipes burst outside of the home (exterior)
Pipes burst inside of the home (interior)
Roof leaks
Damage to heating system
Electrical damage
Other
If you selected 'Other', please provide detail here:
If pipes burst inside your home, please select the option that best describes the level of damages it caused to the home:
No damages
Minor (pipe leaks contained to small area)
Moderate (some damage to walls, ceilings, and/or floors; home still livable)
Major (significant damage to walls, ceilings, and/or floors; no running water; or house uninhabitable/unsanitary)
Have you applied for FEMA assistance?
Yes
No
Does your home have in need of other maintenance/repairs
not related
to the 2021 Winter Storm? Please check all that apply:
Appliance issues
Electrical issues
Flooring issues
Foundation issues
HVAC/heating system issues
Plumbing issues
Roof damages
Sheetrock/insulation issues
Siding damages
None of the above
If your home was damaged by the 2021 Winter Storm, what is your short-term plan for housing?
Stay in the home (damage is not severe enough to leave)
Stay in the home (the damage is severe, but I have nowhere else to go)
Stay with family or friends
Stay in a hotel or motel
Stay in a shelter
I don't know yet
Other Household Impacts
The 2021 Winter Storm affected people in different ways. Other than any home damages, are there other ways in which your household has been impacted by the Winter Storm? Please select all that apply below:
Did the Winter Storm impact your household's wages and employment? Please select all that apply:
Earned less money
Had to close business
Had to take off from work without pay
Lost job
Worked fewer hours
None of the above
Did the Winter Storm impact your household expenses? Please select all that apply:
Had unexpected expenses under $400
Had unexpected expenses over $400
Had to borrow money from family or friend
Had to go into debt (credit card debt or borrow money from bank or lender)
Had to dip into savings
None of the above
Did the Winter Storm impact your household's physical health? Please select all that apply:
Could not get daily medication refilled
Failure of or damage to personal medical equipment
Had a medical emergency
Had an increase in medical expenses
Was not able to social distance
None of the above
Why was your household unable to get daily medication filled?
Due to loss of wages in the household
Due to social distancing or restricted movement
Due to stores running out or not being able to find it
Other
Why did your household seek emergency medical help?
Due to home damages caused by weather conditions
Due to lack of medication
Due to failure of or damage to personal medical equipment
Other
Did the winter storm impact your family's well-being? Please select all that apply to your current situation:
Did not have access to diapers, formula, or sanitary products
Did not have enough food to feed my family
Did not have household goods (soap, toilet paper, paper towels)
Did not have ways of accessing safe drinking water
None of the above
Did you prepare for the 2021 Winter Storm? If so, how? Please check all that apply:
Checked local emergency updates and recommendations
Collected and safely stored important documents
Made a disaster kit (extra water, supplies)
Made a disaster plan (planned to stay elsewhere, evacuation, family communications, etc.)
Prepared my home for impact (wrapped pipes, filled generators, etc.)
No, I didn't think it was necessary to prepare
No, I wasn't able to prepare
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Needs
As a result of the 2021 Winter Storm, what do you anticipate your family will need in the next 2-3 months?
Please note that this is not an application for assistance.
Please select all that apply:
Drinking water
Emergency home repair assistance (tarping for roof, home clean out/mucking & gutting, plumbing repairs, etc.)
Food assistance
Household/personal items (diapers, formula, prescriptions)
Legal aid
Rental/mortgage assistance
Stress relief and mental health services
Temporary housing/relocation assistance
Transportation assistance
Utility assistance
Other
None
If you selected 'Other', please specify what needs you think you will have:
Household Demographics
Household Composition
Number of children 5 years old or younger. Please enter "0" if none
Number of children from 6 to 17 years old. Please enter "0" if none
Number of adults from 18 to 64 years old. Please enter "0" if none
Number of seniors 65+ years old. Please enter "0" if none
Total Number of Household Members
Is there someone
who self-identifies as having a disability
in the household?
Yes
No
Is there a veteran or active duty service member living in your household?
Yes
No
Total
Household
Income for month of January 2021
Please estimate the total income for the
entire
household for the month of January 2021
(before taxes and deductions).
Total Income - January 2021. Please enter "0" if none. Please do not use commas.
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Primary Household Member Information
Please note: We will
never
share your name, address, or any personally identifiable information with any government entity.
First Name
Last Name
Phone Number
Email
Preferred Method of Contact
Please select...
Phone call
Text
Email
Alternative Phone Number
Street Address
City
Zip Code
County
Please select...
Austin
Brazoria
Chambers
Fort Bend
Galveston
Harris
Liberty
Montgomery
Waller
Colorado
Matagorda
Walker
Wharton
What is the primary language spoken at home?
Please select...
English
Spanish
Vietnamese
Arabic
Chinese
Other
If you selected "Other," please specify your preferred language below:
Consent & Release
Are you interested in receiving text notifications about local, free resources and services in our area? Connective Texts is a free service that sends subscribers 2-3 texts with local resources per week.
Your information will not be used for any purpose other than targeting local resources to you, and you can opt-out at any time by texting "STOP".
If so, please click "Yes" below.
Yes, send me texts with local resources
No, I do not want to receive these notifications
Connective works in collaboration with other community-based nonprofit organizations to help residents in our community recovery. May we share your information with other nonprofit organizations involved in disaster recovery efforts?
By responding "Yes," you are agreeing to the following: I authorize Connective to share my information, including my name and address with other disaster relief and voluntary organizations in partnership with our organization in order to coordinate disaster relief assistance. I understand that my information will be shared with participating members of my county's Long-Term Recovery Committee in order to direct community resources. I understand that I may revoke this consent at any time by contacting Connective (info@connectivetx.org).
Yes
No
Contact Information