2022 Connective
Storm
Needs Assessment - Registry
Impacted by the recent storm?
Please fill out this 5 minute 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
Primary Household Member Information
First Name
Last Name
Phone Number
Email
Preferred Method of Contact
Please select...
Phone call
Text
Email
Alternative Phone Number
Address Search
Please type your street address and city, and then click on the matching result. Please do not include apartment numbers or unit numbers.
Were you able to find you address on the map?
Yes
No, I couldn't find my address and I would like to enter my address manually
Street Address
Unit or Apartment #
City
State
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:
Living Situation
Do you own the home that you were living in prior to the storm?
Yes
No
What best describes your living situation before
the storm
?
I was a renter
I was homeless (I was staying in a hotel, shelter, family/friend's home temporarily prior to
the storm
)
Other
If you selected "Other", please provide detail here:
Which of the following best describes where you lived before
the storm
hit?
Single-family home
Apartment
Mobile home
Duplex/fourplex
Condo
Townhome
Home Damage
Was your home damaged by
the 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 insurance companies and other relief agencies should assistance become available.
Was there flooding damage?:
Yes
No
What was the level of the flooding waters?:
Affected: Water did not enter the house or structure
Minor: 1 - 18 inches in first floor of the house or structure
Major: Waterline above 18 inches, the electrical outlets, the basement is completely full
Was there any fire damage?:
Yes
No
Is there wind damage to your residence or on your property?
Yes
No
What is the extent of the damage to the home?:
Affected (missing shingles / siding, broken screens / fences, damage to landscaping, porch, carport)
Minor (
home damaged but livable;
some damage to walls, ceilings, and/or floors; damage to HVAC, plumbing, or electrical system)
Major (
house uninhabitable/unsanitary;
significant damage to walls, ceilings, and/or floors; cracks in foundation, crumbling / collapsing roof)
Destroyed (complete failure of roof or load bearing walls, residence has collapsed)
Household Members
Does anyone in the household self-identify as having a disability?
Yes
No
Are any household members aged 65 years or older?
Yes
No
Is there a veteran or active duty service member living in the household?
Yes
No
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
Would you like us to share your information with
local government entities
responding to disasters in your area?
This information would be used to coordinate response efforts and to advocate for more resources for our community. If you are uncomfortable with us sharing individual level data with government entities, please respond no, in which case, we will only do so with nonprofit agencies (if you selected 'Yes' on the previous consent statement).
Yes
No
Next Survey
Do you have time to answer a few more questions about your needs right now? It will only take 5-10 minutes.
Yes
No
Contact Information