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Harvey Survivors Questionnaire
For those deaf who sustained loss of residence and/or belongings due to Harvey Hurricane. Deadline is Feb 28, 2018
Email address *
1: First & Last Name(s): if married or living together (common-in-law), please list both: *
Your answer
2: Date of Birth (month, day & year): *
Your answer
3: Telephone Number of Main Contact Person (VP & Text numbers): *
Your answer
4: Email Address of Main Contact Person: *
Your answer
5: Address of the Damaged or Flooded Home (Street, City, State & Zip Code): *
Your answer
6: Did you move? *
7: If YES, please tell us your new address (street, city, state & zip code): *
Your answer
8: If you already moved back to the flooded house at later date, please provide the date you moved back (month, day & year):
Your answer
9: If you still plan to move back to the house but have not moved in yet, what is the guess date you will move back? (month, day & year):
Your answer
10: Number of family members living with you before the flood or hurricane damage. *
Your answer
11: Names of family members & their ages.
Your answer
12: Was your house, duplex, or apartment where you live flooded? *
12a: Residence: *
Apartment or Condo
13: What was damaged in your owned residence (i.e. sheetrock, floor, roof leak, etc)? *
Your answer
14: What personal/property items were lost or damaged in Hurricane Harvey (pictures, clothes, furnitures, etc)? *
Your answer
15: Were your cars declared total loss by your insurance company? *
15a: If YES, will you be able to provide proof of the document from the insurance company showing total loss if the Committee asks for it? *
16: Amount of hurricane flood in the house, please select one: *
0" to 6"
Up to 2 feet
More than 2 feet
Amount of hurricane flood in the residence, please select one:
17: Did you lose work income because the company you work for was shut down or closed & you cannot go to work? *
17a: If yes, name of your company, your position, and phone number (can be your supervisor or human resource):
Your answer
18: Have you received any funds? If so, how much & from who? (such as FEMA, Red Cross, Salvation Army, Federal/State Funds, GoFundMe, etc.)
Your answer
19: Any other comments you feel the Committee needs to know:
Your answer
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