PLEASE REVIEW AND ADD COMMENTS

QUESTIONS CAN NO LONGER BE UPDATED, FORMS ARE IN PRODUCTION AND WILL SOON GO TO PRINT!!!!!!

This document will not be used for canvassing; a separate, scannable-data form will be produced based off of this set of questions.

CONVENTIONS

Questions should be yes/no/not applicable wherever possible, or multiple choice. Free-input fields limit ability to search and use data.

Sections/topics are numbered, followed by a hyphenated subnumber for each question in that category.

Additional questions added and asked by each individual organization can be given letters to distinguish from shared data set. Example: 3-A instead of 3-1. These questions can be added within categories if desired as long as this convention is adhered to.

Underlined questions are still being considered for inclusion.

NOT SHARED BY DEFAULT

No one home__ [only used if forms have pre-populated addresses]

Name

Phone

Address (fill in before approaching door)

(If translator needed) What language?

[Do not contact__]

SHARED DATA (not asked/prepopulated)

ASSESSMENT ID # (to track information without including contact info)

SHARED QUESTIONS/DATA (no contact info shared)

4. HOUSING

Are you living here now?

Do you rent or own?

>>[If renter]: Are you having issues with your landlord? [needs revision/rephrasing]

If not, are you currently staying in temporary housing?

Temporary Rental __ Friends/Family__ Shelter__ Hotel__ Other__

Are you in need of housing?

Was your home flooded?

Have you noticed any mold growing (any color: green, white, black)?

Does your home still need help with: demolition? __ mold? __ rebuilding? __

Are you planning to stay here long-term?

3. UTILITIES

Do you have functioning:

Heat?
Electricity?
Gas?
Phone?
Plumbing/Sewage?
Hot water?

2. FOOD/WATER

2-1 Do you have running water?

2-3 Has your water been tested for contaminants?

2-4 Do you have regular access to food when you need it?

1. HEALTHCARE

1-1 Does anyone in your household want to speak to a physical or mental health care professional?

1-2 Are you able to access health care when you need to?) (or has your access to healthcare been affected by the storm?)

5. DEMOGRAPHIC/EDUCATION

FROM SI: How many people live here?____ Children? ___ Senior Citizens? ___ Disabled? __

Are there any children living here?

Rockaways only: How many enrolled in school? Ages?

Do you think your area would benefit from more:

Tutoring__ Public schools__ Teachers__ Books/school supplies__)

Do you know anyone who would benefit from classes for:

GED__ English__ Tutoring for school__

Any seniors living here?

Anyone with disabilities?

6. LEGAL

Would you like to speak to a lawyer about:

Landlord? ___ FEMA or Insurance? ___Mortgage? ___ Workplace? ___ Immigration? ___

[Prepare response to questions about cost, etc. “How much will it cost me?”] IT’S FREE!!

7. EMPLOYMENT

Are you working:

temporarily__ part time__ full time__ not working__

Has your employment been affected negatively by the storm?

8. ASSISTANCE

Have you applied for:

FEMA aid?

>>IF NO: Deadline is March 29th, would you like the FEMA helpline number?

[FEMA Helpline: 800-621-3362]

>>IF YES: Do you need help with the process?

Have you filed an appeal?

SBA Loan?

>>IF NO: Deadline is March 29th SBA Helpline: 800-659-2955

[“What’s SBA?”]

(Answers: DID NOT APPLY, APPLIED, RECEIVED ASSISTANCE, DENIED)

If FEMA told you to apply for an SBA loan, it's very important that you apply even if you don't plan to accept the loan, because SBA applicants who are denied a loan may be eligible for more FEMA benefits.

The SBA Deadline is March 29. SBA Helpline: 800-659-2955.

If you have questions, please call the legal services on your resource list.

Do you want to receive updates about this type of info in the future?

Have you received assistance from:

Rapid Repair?

IF YES: Do you need any more services from them?

[“What’s RR?”]

Red Cross

Local organization

Which? (free field?? direct to put in notes?)

Do you have flood insurance?

Have you received a flood insurance payment?

8_SI. OTHER RESOURCES

SI Only>> Do you need assistance replacing damaged:

furniture?
appliances?

9. COMMUNITY

Would you like to volunteer to assist others recovering from the storm?

Would you participate in a process to help decide how recovery funds are spent in your area?

Would you like to receive notifications about community organizing events in your area?

[Rockaways: IF YES: Make sure to pass on flyer with our resident celly loop]
>>If YES: Would you like to participate in discussions about climate change or renewable energy resources?

Is there a question you think should have been asked in this survey, and if so, what is that question and what would your answer be?

[Archived suggestions, will not be asked]

Immigrant/undocumented? (Robert: would be best to not record whether residents are undocumented; legal teams can follow up on “other” question above)

Do you have health insurance? <<applies to individual, this is a household assessment

2-2 Is your tap water drinkable?

What’s your level of educational level? <<Susannah: potential for bad dynamic.

Do you need assistance acquiring clothing? (SI only? Do other regions have this capacity? Sofia: no.)

Are there sufficient educational resources in your neighborhood?

If your community had a million dollars to spend on Sandy relief, what would your top spending priority be?

How was it treated?

Suggested order:

Housing

Utilities

Food / Water

Medical

Assistance

Employment

Legal

Demographic/Education

Other Resources (SI only)

Community

Original order:

Healthcare