Disaster Relief Center
Disaster Case Management Program
Were you impacted by one of the following disasters?
*
Kern County Flooding
Madera County Flooding
Mariposa County Flooding
Merced Flooding
Tulare Flooding of 2023
How were you impacted by the disaster indicated above?
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Temporarily Evacuated from Primary Residence
A Primary Residence was Totally Destroyed
A Primary Residence was Partially Damaged or Destroyed
Secondarily Displaced
Disaster Related job loss affects their ability to remain in their primary residence
Other
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Contact Info
Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
*
Phone
Email
Mail
May We Leave a Message?
*
Yes
No
Disaster Address (What was the impacted address?)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Residency
*
Yes
No
Which of the following best describes the residence listed at the disaster address?
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Single Family/Multi-Family House
Mobile Home/Trailer/ 5th Wheel/ RV
Apartment/Condo/Cottage
Duplex
Add-On/Mother-In-Law Unit
Hotel/Motel
Homeless/Temporary Shelter
Long Term Care Facility/Home
Other Residence
If Other, Please Specify
*
Did the survivor own or rent the property at the listed disaster address?
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Own
Rent
Other
Trailer-Mobile Home Ownership
*
Owns Structure, Owns Lot
Owns Lot, Rents Structure
Rents Structure, Rent Lot
Owns Structure, Rents Lot
Was the survivor participating in Section 8 housing at the time of the disaster?
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Yes
No
Unsure
Is the survivor currently living at the disaster address?
*
Yes
No
What Is Your Current Mailing Address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Type Of Unit Is The Survivor Living In Now?
*
Single Family/Multi-Family House
Mobile Home/Trailer/ 5th Wheel/ RV
Apartment/Condo/Cottage
Duplex
Add-On/Mother-In-Law Unit
Hotel/Motel
Homeless/Temporary Shelter
Long Term Care Facility/Home
Other Residence
If Other, Please Specify
*
How long do you anticipate staying at this current residence?
*
Temporary (Less than 3 months)
Short Term (3-6 months)
Long Term (6 months - 1 year)
Permanent (longer than a year)
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Other
Ethnicity
*
American Indian or Alaskan Native
Asian
Black/ African-American
Hispanic/Latino
Native Hawaiian or other Pacific Islander
White/Caucasion
Rather not say
Other
Preferred Language
*
Spanish
English
Hmong
Punjabi
Other
Marital Status
*
Single
Married
Seperated
Divorced
Domestic Partner
Common Law
Other
How Many People Live In Your Household Including Yourself?
*
Who, if anyone, currently lives with you in your household? Please include permanent residents only.
*
Rows
First and Last Name
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Do you have any pets, if so how many?
*
How many children are in your household?
*
What are the age groups of your children, if any?
Rows
Children
1.
2.
3.
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Employment History
Have you or anyone in your home ever served in the branch of the United States Military
*
Yes
No
Other
Which of the following categories best describes your employment status?
*
Employed, working full time
Employed, working part time
Not employed, looking for work
Not employed, NOT looking for work
Retired
Disabled, not able to work
Other
If you are unemployed or underemployed are you interested in job placement assistance?
*
Yes
No
If looking for job placement assistance, what industry/field are you looking for work in (list up to three):
*
Rows
Industry/Field
1.
2.
3.
How many people living in your household are currently employed or looking for work?
*
1
2
3
What is your annual household income?
*
What is your current household income?
*
What benefits do you currently receive?
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Medicare
Medicaid
Social Security Benefits
Supplemental Security Income Benefits (SSI)
Social Security Disability Insurance (SSDI) Benefits
Calfresh/ Food Stamps
None of the Above
Other
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Vulnerabilities
Please Select All That Apply
*
Urgent Basic Needs Assistance
Immediate Medical Needs Assistance
Safety Risk
Housing Insecurity
Poverty
Unemployment
Elderly (65+)
Minor Child (without parent or guardian)
Single Head of Household (with minor children)
Disabled
Uninsured/Underinsured
Isolated
Experiencing Emotional Distress
Limited Literacy
Limited English Proficiency
Limited Access to Transportation
Limited Access to Information
Priority Population 1
Access and Functional Needs
No Current Vulnerabilities
Other
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Disaster Related Needs
What types of disaster related needs does this survivor household have? (check all that apply)
*
Advocacy
Clothing
Children and Youth Services
Domestic Animal Assistance
Education or Job Training
Employment Assistance
Funeral Assistance
Functional Needs Assistance
Food/Nutrition
Household Appliances
Household Furniture
Household Goods
Housing Assistance
Legal Assistance
Emotional/Spiritual Care
Medical Assistance
Medical Insurance
Missing Person Assistance
Removal of Debris
Repair/Rebuild – House/Dwelling
Repair/Rebuild – Household systems
Repair/Rebuild – Other property/structures
Transportation
Utilities
No Disaster Related Need
Other
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Ultimate Housing Preference
Ultimate Housing Preference at time of seeking services (check 1)
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Remain in County as a Renter
Remain in County as an Owner (Repair/Rebuild/Purchase on original site)
Remain in County as an Owner (New Build/Purchase on new site)
Remain in County – Ownership Status Undecided
Remain in County – Other (please specify)
Leave County as a renter
Leave County as an Owner (New Build/Purchase)
Leave County – Ownership Status Undecided
Leave County – Other (please specify)
Undecided at this time
If Renter/Owner – Other, please specify
If Other, Please Specify
*
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Post-Disaster Assistance
Have you received assistance from any organization since the disaster occured?
*
Yes
No
Unsure
Did you apply to FEMA?
*
Yes
No
Unsure
What is your Fema Registration Number?
*
What benefits have you received?
*
Did you apply to the Red Cross?
*
Yes
No
Unsure
What is your Red Cross Number?
*
Who else did you receive assistance from post disaster?
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United Way
Catholic Charities
Clovis Hills
Salvation Army
Shaver Lake Lions Club
Central Sierra Historical Society’s Resiliency Fund
Rebuild Our Sierra
Other
What kind of assistance did you receive?
*
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