Form DHS Form 801 DHS Form 801 Survey of Businessess

Department of Homeland Security
Private Sector Office
SURVEY OF BUSINESSES

OMB control number: 1601-NEW
Expiration date: mm/dd/yyyy

Purpose: The purpose of this survey is to assess the specific needs of the [LOCATION] business community as
well as the effectiveness of the initial recovery effort following [EVENT].
Pledge of confidentiality: Participation in this survey is voluntary. Individual responses will not be revealed to any
unauthorized party; however, responses can and will be used for law enforcement purposes.
18 USC §1001 prohibits any false statement, oral or written, to a government agent or agency in an official manner.
An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information unless it displays a current valid OMB control number and an expiration date. The control number for
this collection is 1601-NEW and this form will expire on mm/dd/yyyy. The estimated average time to complete this
survey is 15 minutes per respondent. If you have comments regarding this survey you can write to:
Gary S. Becker, Department of Homeland Security, Private Sector Office, Washington, DC 20528;
[email protected] ; (202) 282-9013
Instructions: Provide a response to all questions (except 10-12 if no paid employees), even if the response is
“Unknown”, “Refused”, or “Not Applicable”. For questions marked “Not Applicable”, explain why. Please make
answers as specific as possible. Where specific numbers are not available, best approximations are welcomed.

PLEASE PRINT LEGIBLY
Company: ___________________________________________________________________
Zip: _____________
Address:
Cross St.: _______________________________ County (Parish): ______________________
Your Name: _________________________________________________________________
Company Point of Contact (if different): ___________________________________________
Phone: _____________________________ Cell: ____________________________________
Fax: _______________________________ Email: ___________________________________
What is the primary function of this business? _________________________________
Is the company’s address also a residence? Yes / No
Does your business have more than one establishment? Yes / No
If yes, how many? ______
How many were affected by [EVENT]? _______
1.

Immediately following [EVENT] on [DATE] your business: (Circle One)
Suspended all operations
Have operations resumed?

2.

Suspended some operations
Yes / No

Maintained all operations

If yes, what date? _________________

What is the estimated sales volume loss since [DATE]?
$___________________
What is your current sales volume compared to before [EVENT]? (Circle One)
100% or better

80-99%

50-79%

20-49%

0-19%

3.

Did your business or any establishments in your business relocate? Yes / No
If yes, where to? ___________________________________________________

4.

How much damage did your business sustain?
Building
$_________________________
Inventory
$_________________________
Equipment
$_________________________
Other
$_________________________
TOTAL
$_________________________

5.

What part of your business did [EVENT] affect the most? (Circle all applicable)
Inside Building

DHS Form 801 (1/07)

Outside Building

Inventory

Equipment

Other_____________
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6.

Was your business insured against an event such as [EVENT]? Yes / No
If only partially insured, please explain _____________________________________________________
_____________________________________________________________________________________

7.

Have you filed a claim yet on insured goods? Yes / No
If yes, have you received any payment for your claim? Yes / No / Claim Rejected
How long did it take? ______________________________

8.

Did you lose any of the following services after [EVENT]? Please indicate if and when any lost services were
restored.

Service

Service Lost? (Y / N)

Restored? Please include approximate date

Electricity
Telephone
Natural Gas
Water and Sewer
Mail
9.

Aside from owners or partners, does your business have any paid employees? Yes / No
If no paid employees, please skip to question 13

10. How many employees did your business have prior to [EVENT]? _____
How many employees are available for work now? _____
Does your business have enough labor to maintain operations? Yes / No
11. Are you able to meet payroll? Yes / No

If so, for how long? _____________

12. How many of your employees can you confirm have housing? _____ (Include # or circle one below)
All

Most

Some

None

13. Does your business plan to declare bankruptcy? Yes / No / Unsure at this time
14. Please describe any other obstacles preventing your business from operating fully.

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Please use the rest of this space for any other comments, concerns or needs you have.

DHS Form 801 (1/07)

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