JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Wood River Flood Needs Assessment
Please fill this out with as much information possible. We need ONE assessment per household.
Encourage anyone you know in Wood River to fill this out. We want documentation from everyone!
This will help us get resources we need.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Phone #
*
Your answer
Address
*
Your answer
Email Address
Your answer
# of people in the home:
*
Your answer
How was your home affected by the flood?
*
Your answer
What are your short-term needs?
*
Food
Water
Hygiene Items
Cleaning supplies
Shelter
Water removed from basement
None
Other:
Required
Any more short-term needs not listed OR additional information you would like to provide:
Your answer
What are your long-term needs?
*
Furnace Fixed/Replaced
Water heater fixed/replaced
Structure Repair
Electric work
None
Other:
Required
If there is structure repair, please explain:
Your answer
Any more long-term needs not listed OR additional information you would like to provide:
Your answer
****If you've already replaced items, please explain what you have purchased. KEEP YOUR RECEIPTS, as it may be possible to receive reimbursement. Explain your losses and what you've replaced below:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Heartland United Way.
Report Abuse
Forms
