2018 Marshalltown Tornado Response
Homeowner Assistance Request Intake Form
Name *
Your answer
Phone number
Your answer
Alt Phone number
Your answer
Email
Your answer
Address Damaged *
Your answer
Are damages covered by insurance?
Have you applied for (check all that apply)
Description of home (to help identify correct home)
Your answer
Ages of all household members
Your answer
Does any household member have special needs?
Your answer
Does homeowner need to be present for work to be completed?
Is the occupant the legal property owner?
DAMAGE ASSESSMENT:
DAMAGE ASSESSMENT NOTES:
Your answer
SAFETY: Power lines down on property?
SAFETY: Trees and power lines entangled?
SAFETY: Trees resting on power lines?
SAFETY: Unrestrained animals on property?
SAFETY: Other Info
Your answer
TARPING: Which structures require tarps?
TARPING: Size of required tarp(s)
Your answer
TARPING: Is roof stable to walk/work on?
Your answer
TARPING: Need help installing tarp?
TARPING: Other info
Your answer
TREE WORK: Trees/limbs on
TREE WORK: Trees/limbs blocking access to
TREE WORK: Number of trees needing cut
Your answer
TREE WORK: Size of trees needing cut
Your answer
TREE WORK: Other info
Your answer
DEBRIS: Public Works sent them to 2-1-1 to get volunteer help to move debris to curb?
DEBRIS/DEMOLITION: Non-vegetative debris on property?
DEBRIS/DEMOLITION: Inside structure(s)?
DEBRIS/DEMOLITION: Debris blocking access to
DEBRIS/DEMOLITION: Heavy machinery required?
DEBRIS/DEMOLITION: Unsalvageable structure(s)?
DEBRIS/DEMOLITION: Other info
Your answer
FENCING: Is there fence work?
FENCING: Containing Livestock?
FENCING: What type of fence?
Your answer
FENCING: Appx. length of fence needing work?
Your answer
FENCING: Equip. required & other info
Your answer
WATER DAMAGE: Water level in home
WATER DAMAGE: Is there currently water in the home
WATER DAMAGE: Part(s) of house affected by flooding
Your answer
WATER DAMAGE: Removal of damaged appliances, furniture, flooring or personal belongings needed?
WATER DAMAGE: Did any drywall get wet
WATER DAMAGE: Do you need it removed?
I authorize the Central Iowa RSVP to release information that is considered relevant and necessary for the purpose of determining assistance to other partner agencies involved in disaster relief.
Any other additional notes or information that would be helpful?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service