Disaster Relief Site
Property & Personal Information
Request Date
-
Month
-
Day
Year
Date
Resident Name
First Name
Last Name
Cell Phone Number
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Neighborhood/Village
Type of Residence
House
Apartment
Townhouse/Condo
Mobile Home
Please check if you are or have any of the following:
Older than 60
Children in Home
First Responder
Unrestrained Animals
Flood Insurance
Is it okay to work without resident present?
Yes
No
Any special needs?
Muck Out Needs
Please list overview of work needed:
Height of Water:
0-3in
3-6in
6-12in
12-18in
18in-2ft
2-3ft
3-4ft
4-5ft
5-6ft
6-7ft
7-8ft
Above the Ceiling
In the Attic
Over the House
Please Check What is Needed:
Carpet Removal
Hardwood Floor Removal
Tile
Drywall Removal
Appliance Removal
Heavy Item Removal
Tree Work & Roof Needs
Tree Work - Number of trees 1-18 inches wide
0
1
2
3
4
5+
Tree Work - Number of trees wider than 18 inches
0
1
2
3
4
5+
Tarping Needs - Select all that apply
House Roof Damage
Outbuilding Roof Damage
Number of Tarps 20' X 30' Tarps Needed
Debris & Garbage - Select all that apply
Non-vegetative Debris
Vegetative Debris
Debris Description
Claim, Status and Report
To be completed by workers
Team Assigned
Current Status
Open, unassigned
Open, assigned
Open, partially completed
Open, needs follow-up
Closed, completed
Closed, incomplete
Closed, out of scope
Closed, done by others
Closed, no help wanted
Status Update
Submit
Should be Empty: