ALLEGANY COUNTY FLOOD RECOVERY INTAKE FORM - 2026

  • ALLEGANY COUNTY FLOOD RECOVERY INTAKE FORM - 2026

  • INTAKE BASICS

  • 1. How this intake form is being completed*
  • 2. Today's date *
     - -
  • 3. Applicant has completed the NYS Self-Reporting tool (if applicable)

  • PERMISSION STATEMENT

  • 4. The Intake Applicant listed below hereby grants permission to United Way of Cattaraugus & Allegany Counties to use the details provided in this document for the express purpose of coordinating and providing aid to the applicant and/or applicant's family following a disaster, effective at the date of intake and for the duration of the recovery efforts. No information will be altered without prior written consent, nor will it be used for commercial purposes. A collection of all data gathered may be used anonymously for educational or research purposes.

  • Permission*

  • INTAKE APPLICANT INFORMATION

  • Format: (000) 000-0000.
  • 8. Phone Type*
  • 9. Can we send text messages to this number?*
  • Format: (000) 000-0000.
  • 12. What is your preferred method of contact?
  • 14. Applicant Age
  • 15. Applicant Gender

  • SELF-REPORTED AT-RISK POPULATION

  • 16. Special or at-risk population affected at this residence

  • HOUSEHOLD OCCUPANT INFORMATION

  • The value must be a number
  • 19. Domesticated pets living in the home
  • 20. Foster/other care is needed for my pets

  • ACCESS TO DWELLING

  • 21. Regarding the driveway of the home
  • 22. Is there a private bridge to the home?
  • 23. Regarding the bridge to the home
  • 24. Prior to the flood, was there a ramp that provided accessibility into the home?
  • 25. Regarding the previously-existing ramp

  • DAMAGED DWELLING ADDRESS INFORMATION

  • The value must be a number
  • 29. County*
  • 31. Applicant has taken photos of home / property damage*
  • 32. Applicant is saving receipts of any purchases made related to the flooding (including items used for cleaning.)*
  • 33. Dwelling type*
  • 34. Is this your primary residence?*
  • 35. Does the applicant own or rent the premises?*
  • 37. Is this a working farm?
  • 38. Have you contacted Ag & Markets to report your damage
  • 39. Would you like to be referred to Cornell Cooperative Extension for assistance in working with Ag & Markets?
  • 40. Rate the level of Flood damage to the property*
  • 41. For dwellings self-reported as MAJOR or DESTROYED, do we have applicant permission to make a referral to Red Cross to evaluate for assistance?
  • 42. Is there a basement?
  • 44. Was there water in the essential living space?
  • 47. Today, there is still standing water in the home.*
  • 48. The dwelling has been cleaned and "mucked out."
  • 49. Has a mold remediation treatment been administered. (Bleach is not sufficient; flood damage should receive "shock wave" treatment to kill mold spores.)
  • 50. Would you like a referral for the muck out and/or mold abatement volunteer teams, if they are available?
  • 51. Are you able to return to this residence today?*
  • 52. If no, do you think you will be returning to this residence in the future?*

  • CURRENT ADDRESS INFORMATION (if different from damaged dwelling)

  • 54. Is current location status long term?
  • 56. Will you need help to find housing?

  • SELF-IDENTIFIED DISASTER-CAUSED UNMET NEEDS

  • 57. Self-identified disaster-caused unmet need(s). Check all that apply.

  • BEHAVIORAL HEALTH ASSESSMENT

  • 58. Is disaster survivor or anyone in the household in distress or mental health crisis?
  • 59. Would this person(s) like to speak to a crisis counselor about coping with disaster-related stress?
  • 60. Can we provide your contact information to a counselor for referral?

  • CHILDREN AND YOUTH ASSESSMENT

  • 61. Are there children in the household?
  • 62. Prior to the disaster, were any of these children in early education/childcare?
  • 63. Were the services disrupted as a result of the disaster?
  • 64. Does the disaster survivor currently have a need for childcare?
  • 66. Would you like a referral to ACCORD's Child Resource Center?
  • 67. Have any children in the household missed any scheduled checkups or immunizations since the disaster?
  • 68. Is disaster survivor caring for a foster child or foster children?
  • 69. Do you have any concerns about how the child(ren) is managing feelings and/or behaviors post-disaster?
  • 70. Would you like a referral to a counselor?

  • INSURANCE / FINANCIAL

  • 72. Does the applicant have homeowners / renters insurance?*
  • 74. Does the applicant have flood insurance?*
  • 75. Has insurance carrier been contacted?
  • 76. Have you incurred any out-of-pocket expenses related to flood damage?
  • 78. If requested, are receipts available?

  • FINANCIAL ASSESSMENT

  • Pre-Disaster Financial Information
  • 80. If your household is income-eligible based on 200% of Federal Poverty Guidelines for family size, would the applicant like to be referred to Department of Social Services to determine eligibility for assistance (such as SNAP, HEAP, other government assistance)? NOTE: This does not determine eligibility for other forms of assistance.
  • Would the applicant like to be referred to Department of Social Services to determine eligibility for assistance?
  • 83. Was the disaster survivor or any household member receiving any of the following prior to the disaster:*
  • 84. Does the household have more than $15,000 in asset accounts (checking, savings, IRA 401-K, DC, etc.)?*
  • 85. Is the applicant or any other affected household member a veteran?*

  • FOOD ASSESSMENT

  • 86. Does applicant have enough food to feed all members of the household?
  • 87 Before the disaster, was the applicant or any household member receiving any of the following food assistance?
  • 88. Does the applicant need referral for food assistance?

  • CLOTHING

  • 89. Did any member of the household lose clothing as a result of the disaster?
  • 90. What type(s) of assistance is needed

  • FURNITURE/APPLIANCES/PLUMBING/ELECTRIC ASSESSMENT

  • 92. Did applicant have any of following destroyed in the disaster
  • 93. Has the applicant submitted a claim to their insurance (if any)?
  • 94. Did the applicant get replacement items from any non-profit organizations or other community supports?
  • 95. Does the applicant need referral for appliance installation (IE water heater, furnace, etc.)

  • WHAT HAPPENS NEXT?

    If you requested referrals to various services, those organizations will be contacted on your behalf. Eligibility for various resources will be determined; you will be contact for additional information, as needed. Based on eligibility, coordination of benefits and resources among community partners will be provided. Expect further follow up as the process unfolds.

  • THANK YOU!

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