Apply for Home Repairs or Reimbursement
Needs Assessment Survey
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2021 Connective Storm Needs Assessment - Registry
Impacted by the recent storm?
Please fill out this 5 minute survey to share your needs with local non-profits. Your participation will allow us to advocate for more resources for our community and strengthen recovery efforts. This isn’t an application for assistance, but you can opt-in to receive text messages about new resources as they become available
Primary Household Member Information
Preferred Method of Contact
Alternative Phone Number
Please type your street address and city, and then click on the matching result. Please do not include apartment numbers or unit numbers.
Were you able to find you address on the map?
No, I couldn't find my address and I would like to enter my address manually
Unit or Apartment #
What is the primary language spoken at home?
If you selected "Other," please specify your preferred language below:
Do you own the home that you were living in prior to the storm?
What best describes your living situation before
I was a renter
I was homeless (I was staying in a hotel, shelter, family/friend's home temporarily prior to
If you selected "Other", please provide detail here:
Which of the following best describes where you lived before
Was your home damaged
We're very sorry to hear that. Make sure to take as many pictures of the damage as possible. Taking pictures will be useful in proving losses insurance companies and other relief agencies should assistance become available.
What was the extent of the damage?:
Affected (missing shingles / siding, broken screens / fences, damage to landscaping, porch, carport)
home damaged but livable;
some damage to walls, ceilings, and/or floors; damage to HVAC, plumbing, or electrical system)
significant damage to walls, ceilings, and/or floors; cracks in foundation, crumbling / collapsing roof)
Destroyed (complete failure of roof or load bearing walls, residence has collapsed)
Was there flooding damage?:
What was the level of the flooding waters?:
Affected: Water did not enter the house or structure
Minor: 1 - 18 inches in first floor of the house or structure
Major: Waterline above 18 inches, the electrical outlets, the basement is completely full
Does anyone in the household self-identify as having a disability?
Are any household members aged 65 years or older?
Is there a veteran or active duty service member living in the household?
Consent & Release
Are you interested in receiving text notifications about local, free resources and services in our area? Connective Texts is a free service that sends subscribers 2-3 texts with local resources per week.
Your information will not be used for any purpose other than targeting local resources to you, and you can opt-out at any time by texting "STOP".
If so, please click "Yes" below.
Yes, send me texts with local resources
No, I do not want to receive these notifications
Connective works in collaboration with other community-based nonprofit organizations to help residents in our community recovery. May we share your information with other nonprofit organizations involved in disaster recovery efforts?
By responding "Yes," you are agreeing to the following: I authorize Connective to share my information, including my name and address with other disaster relief and voluntary organizations in partnership with our organization in order to coordinate disaster relief assistance. I understand that my information will be shared with participating members of my county's Long-Term Recovery Committee in order to direct community resources. I understand that I may revoke this consent at any time by contacting Connective (
Would you like us to share your information with
local government entities
responding to disasters in your area?
This information would be used to coordinate response efforts and to advocate for more resources for our community. If you are uncomfortable with us sharing individual level data with government entities, please respond no, in which case, we will only do so with nonprofit agencies (if you selected 'Yes' on the previous consent statement).
Do you have time to answer a few more questions about your needs right now? It will only take 5-10 minutes.