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Tropical Storm Imelda Needs Assessment Survey - English Version



Please fill this out if your home was damaged by Tropical Storm Imelda. Note: This is a survey to understand the needs, not an application for assistance. It will be used to inform response efforts. As resources become available to assist those affected by flooding, we will reach out to share information about those resources.

For "how-to" resources on muck & gut, mold remediation, insurance navigation and more visit: sbpusa.org/start-here.

This not a rescue request. If you or anyone you know is in danger, please call 911 immediately. For social services assistance, please call 211. 

Please complete this by October 15, 2019.
Primary Household Member Information












Impact of Disaster on Household










Client Demographics








Please estimate the annual gross income for the entire household.

Consent & Release
I hereby authorize Harvey Home Connect to share any of my information in its possession, including but not limited to my name, address, other personal information with other disaster relief and voluntary organizations in partnership with our organization in order to coordinate potential disaster relief services and assistance. I understand that my information will be shared with participating members of my county's Long-Term Recovery Group in order to direct community resources. I understand that I may revoke this consent at any time by contacting Harvey Home Connect except when action has already been taken to obtain and/or release such information to member organizations of Harvey Home Connect or participating in the Coordinated Assistance Network. My signature on this release indicates that I have read the above, or had it read to me, and that I understand the terms and conditions. I am also signing this release on behalf of my children that are under the age of eighteen (18).