Immediate Disaster Case Management Intake Assessment

Disaster Survivor Intake

Demographic Information

Current Facility:

First Name:

Middle Name:

Last Name:

Suffix:

Alias:

Disaster Survivor Age:

Gender (circle one): Male Female Undetermined Declined

Marital Status (circle one): Married Single

Ethnicity (circle one): Hispanic or Latino Not Hispanic or Latino Undetermined Declined

Race (circle one):

American Indian or Alaska Native Black or African American White Undetermined

Asian Native Hawaiian or Other Pacific Islander Other Declined

English Speaker (circle one): Yes No Undetermined Declined

Preferred Language (circle one):

English Tagalog American Sign Language

Spanish Vietnamese Other

Chinese Italian Undetermined

French Korean Declined

German Russian

Contact Information

Address:

Apt/Suite:

Address Type (circle one):

Apartment or house that you own Community Shelter Public Housing Retirement Community Other

Room, Apartment, or house that you rent Community Transitional Housing Nursing or Assisting Living Facility Hotel or motel Undetermined

Staying or living in a family member’s room, text an apartment, or house Hospital Place not meant for habitation Declined

Head of Household (circle one): Yes No Undetermined Declined

Number of other individuals in household:

Email Address:

Best Phone Number:

Other Phone Number:

Verification Documentation:

Self-Reported Special/At-Risk Populations

Self-Reported Special/At-Risk Populations (circle as many as apply):

Children Domestic Violence Survivors

Elderly Individuals with Limited English Proficiency

Individual with Disabilities in the household Shelter

Self-Identified Unmet Needs (circle as many as apply):

Behavioral Health Access Finances Legal

Clothing Furniture and/or appliances Transportation

Employment Health Insurance or Health Access Food

FEMA Help Housing

FEMA Tier (circle one):

Tier 1 – Immediate Needs Met Tier 3 – Significant Unmet Needs

Tier 2 – Some Remaining Unmet Needs or in Current Rebuild/Repair Status Tier 4 – Immediate and Long-Term Unmet Needs

FEMA Registration Number:

Disaster Survivor Status (circle one): Active Information Only

Assigned IDCM Worker:

Alternative Addresses and Family Members (Face Sheet) (Page 1 of 2)

Disaster Survivor Name:				Consent Form (circle one): Consent Form Received Consent Form Not Received
Alternative Address:											Apt/Suite:
Address Type (circle one):
Apartment or house that you own Staying or living in a family member’s room, apartment, or house Community Transitional Housing Nursing or Assisting Living Facility Retirement Community Place not meant for habitation Undetermined						Room, Apartment, or house that you rent Community Shelter Public Housing Hospital Hotel or motel Other Declined
Begin Date:			End Date:					Primary Phone:
Family Member/ Household Member Details:
Household Member 1	First Name:				Middle Name:				Last Name:
Age:	Gender (circle one): Male Female Undetermined Declined
Relationship to Head of Household (circle one):
Aunt Father Grandfather Guardian Other Adult Son Step Sister		Brother Foster Parent Grandmother Husband Other Child Under 18 Step Brother Step Son		Caregiver/Nurse Foster Son Great Grandchild Mother Other Relative Step Daughter Uncle			Daughter Foster Daughter Great Grandfather Nephew Self Step Father Wife			Domestic Partner Grandchild Great Grandmother Niece Sister Step Mother
Ethnicity (circle one): Hispanic or Latino Not Hispanic or Latino Undetermined Declined				Race (circle one):
				American Indian or Alaska Native Black or African American White Undetermined					Asian Native Hawaiian or Other Pacific Islander Other Declined
Alternate Contact (circle one): Yes No			Best Phone Number:					Other Phone Number:

Family Member/ Household Member Details:
Household Member 2	First Name:	Middle Name:	Last Name:
Age:	Gender (circle one): Male Female Undetermined Declined
Relationship to Head of Household (circle one):

Alternative Addresses and Family Members (Face Sheet) (Page 2 of 2)

Aunt Father Grandfather Guardian Other Adult Son Step Sister	Brother Foster Parent Grandmother Husband Other Child Under 18 Step Brother Step Son		Caregiver/Nurse Foster Son Great Grandchild Mother Other Relative Step Daughter Uncle	Daughter Foster Daughter Great Grandfather Nephew Self Step Father Wife			Domestic Partner Grandchild Great Grandmother Niece Sister Step Mother
Ethnicity (circle one): Hispanic or Latino Not Hispanic or Latino Undetermined Declined			Race (circle one):
			American Indian or Alaska Native Black or African American White Undetermined			Asian Native Hawaiian or Other Pacific Islander Other Declined
Alternate Contact (circle one): Yes No		Best Phone Number:			Other Phone Number:

Family Member/ Household Member Details:
Household Member 3	First Name:				Middle Name:			Last Name:
Age:	Gender (circle one): Male Female Undetermined Declined
Relationship to Head of Household (circle one):
Aunt Father Grandfather Guardian Other Adult Son Step Sister		Brother Foster Parent Grandmother Husband Other Child Under 18 Step Brother Step Son		Caregiver/Nurse Foster Son Great Grandchild Mother Other Relative Step Daughter Uncle		Daughter Foster Daughter Great Grandfather Nephew Self Step Father Wife			Domestic Partner Grandchild Great Grandmother Niece Sister Step Mother
Ethnicity (circle one): Hispanic or Latino Not Hispanic or Latino Undetermined Declined				Race (circle one):
				American Indian or Alaska Native Black or African American White Undetermined				Asian Native Hawaiian or Other Pacific Islander Other Declined
Alternate Contact (circle one): Yes No			Best Phone Number:				Other Phone Number:

Alternative Addresses Supplement

Disaster Survivor Name:		Consent Form (circle one): Consent Form Received Consent Form Not Received
Alternative Address 1:					Apt/Suite:
Address Type (circle one):
Apartment or house that you own Staying or living in a family member’s room, apartment, or house Community Transitional Housing Nursing or Assisting Living Facility Retirement Community Place not meant for habitation Undetermined			Room, Apartment, or house that you rent Community Shelter Public Housing Hospital Hotel or motel Other Declined
Begin Date:	End Date:			Primary Phone:
Alternative Address 2:					Apt/Suite:
Address Type (circle one):
Apartment or house that you own Staying or living in a family member’s room, apartment, or house Community Transitional Housing Nursing or Assisting Living Facility Retirement Community Place not meant for habitation Undetermined			Room, Apartment, or house that you rent Community Shelter Public Housing Hospital Hotel or motel Other Declined
Begin Date:	End Date:			Primary Phone:
Alternative Address 3:					Apt/Suite:
Address Type (circle one):
Apartment or house that you own Staying or living in a family member’s room, apartment, or house Community Transitional Housing Nursing or Assisting Living Facility Retirement Community Place not meant for habitation Undetermined			Room, Apartment, or house that you rent Community Shelter Public Housing Hospital Hotel or motel Other Declined
Begin Date:	End Date:			Primary Phone:

Household Members Supplement

Family Member/ Household Member Details:
Household Member __	First Name:				Middle Name:			Last Name:
Age:	Gender (circle one): Male Female Undetermined Declined
Relationship to Head of Household (circle one):
Aunt Father Grandfather Guardian Other Adult Son Step Sister		Brother Foster Parent Grandmother Husband Other Child Under 18 Step Brother Step Son		Caregiver/Nurse Foster Son Great Grandchild Mother Other Relative Step Daughter Uncle		Daughter Foster Daughter Great Grandfather Nephew Self Step Father Wife			Domestic Partner Grandchild Great Grandmother Niece Sister Step Mother
Ethnicity (circle one): Hispanic or Latino Not Hispanic or Latino Undetermined Declined				Race (circle one):
				American Indian or Alaska Native Black or African American White Undetermined				Asian Native Hawaiian or Other Pacific Islander Other Declined
Alternate Contact (circle one): Yes No			Best Phone Number:				Other Phone Number:

Family Member/ Household Member Details:
Household Member 2	First Name:				Middle Name:			Last Name:
Age:	Gender (circle one): Male Female Undetermined Declined
Relationship to Head of Household (circle one):
Aunt Father Grandfather Guardian Other Adult Son Step Sister		Brother Foster Parent Grandmother Husband Other Child Under 18 Step Brother Step Son		Caregiver/Nurse Foster Son Great Grandchild Mother Other Relative Step Daughter Uncle		Daughter Foster Daughter Great Grandfather Nephew Self Step Father Wife			Domestic Partner Grandchild Great Grandmother Niece Sister Step Mother
Ethnicity (circle one): Hispanic or Latino Not Hispanic or Latino Undetermined Declined				Race (circle one):
				American Indian or Alaska Native Black or African American White Undetermined				Asian Native Hawaiian or Other Pacific Islander Other Declined
Alternate Contact (circle one): Yes No			Best Phone Number:				Other Phone Number:

Behavioral Health Advocacy Assessment

Assessment Date:
Is Disaster Survivor or anyone in the household in distress? (circle one): Yes No Undetermined Declined
Would Disaster Survivor or anyone in the household like to speak to someone about coping with disaster-related stress? (circle one): Yes No Undetermined Declined
Referral Needed? (circle one):				Yes No Undetermined Declined
Referral Services (circle as many as apply):
Behavioral Health- Other Crisis Counseling Program		Community clinical provider Disaster Distress Helpline	Counseling Services Private Counsel Directory
Notes:

Children and Youth Assessment

Assessment Date:
Is the Disaster Survivor caring for a foster child or foster children? (circle one):		Yes No Undetermined Declined
Prior to the disaster, was the Disaster Survivor’s child in a Head Start Program? (circle one):		Yes No Undetermined Declined
Prior to the disaster, was the Disaster Survivor’s child in childcare? (circle one):		Yes No Undetermined Declined
If yes, were the services disrupted as a result of the disaster? (circle one):		Yes No Undetermined Declined
Does the Disaster Survivor currently have a need for child care? (circle one):		Yes No Undetermined Declined
If child care is needed but child is not getting it, what are the barriers? (circle as many as apply):
Childcare provider closed due to disaster Disaster Survivor relocated to new area Disaster Survivor unable to find childcare for child with disability Community barriers because of disaster Increased childcare costs	Disaster Survivor now unable to afford childcare due to unemployment losses Disaster Survivor unable to access site due to transportation Disaster Survivor unable to find childcare for infant Family care provider can no longer provide care post disaster Other
Prior to the disaster, did Disaster Survivor get voucher assistance for child care? (circle one):		Yes No Undetermined Declined
Was Disaster Survivor receiving child support payments before the disaster? (circle one):		Yes No Undetermined Declined
Are the Disaster Survivor’s children currently in school? (circle one):		Yes No Undetermined Declined
If Disaster Survivor’s children currently in school, are they in the same school district post-disaster? (circle one):		Yes No Undetermined Declined
Has your child missed any scheduled checkups or immunizations since the disaster? (circle one):		Yes No Undetermined Declined
Does Disaster Survivor have any concerns about how his/her child is coping post-disaster? (circle one):		Yes No Undetermined Declined
If yes, please explain in detail. (write here):
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Case Manager Advocacy Childcare Referral to Child Care and referral Agency Referral to Social Services for TANF/ CCDF application School District	Child – Other Head Start/ Early Head Start Referral to Disaster Distress Helpline Referral to VOA/ community group for school supplies Social Services or Family Court for child support payment
Notes:

FEMA/SBA Assessment

Assessment Date:
Does Disaster Survivor have a FEMA registration number? (circle one):
Disaster Survivor has not received	Disaster Survivor received envelope but threw away		Does not know		Yes	No
SBA Application:
Disaster Survivor has submitted SBA application (circle one):		Yes No Undetermined Declined		If yes, SBA Application Submitted Date:
Disaster Survivor has been approved for SBA loan (circle one):		Yes No Undetermined Declined		If yes, Date Approved:
Disaster Survivor has submitted claim for FEMA Individual Assistance (circle one):		Yes No Undetermined Declined		If yes, Submitted Claim Date:
Disaster Survivor has received Non-Comp Notice from FEMA IA (circle one):		Yes No Undetermined Declined		If yes, Non-Comp Notice Received Date:
Disaster Survivor has received FEMA IA Benefit (circle one):		Yes No Undetermined Declined		If yes, IA Benefit Received Date:
Disaster Survivor has received MAX Grant from FEMA (circle one):		Yes No Undetermined Declined		If yes, MAX Grant Received Date:
Disaster Survivor has applied for FEMA Other Needs Assistance (circle one):		Yes No Undetermined Declined		If yes, ONA Application Date:
Disaster Survivor has received ONA (circle one):		Yes No Undetermined Declined		If yes, ONA Received Date:
Disaster Survivor was denied for ONA (circle one):		Yes No Undetermined Declined		If yes, ONA Denied Date:
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Assist with appeal for SBA denial Assist with completion of FEMA ONA Application Assist with FEMA IA denial Assist with FEMA/SBA Sequence of Delivery FEMA - Other Provide education regarding FEMA/SBA Sequence of Delivery Submit inquiry to FEMA IA Branch re: Disaster Survivor’s ONA			Assist with completion of FEMA IA Application Assist with completion of SBA Loan Applications Assist with FEMA ONA denial Case Manager Assistance Obtain signed FEMA Disclosure release from Disaster Survivor Submit inquiry to FEMA IA Branch re: Disaster Survivor’s IA
Notes:

Clothing Assessment

Assessment Date:
Did any of the household members lose clothing as a result of the disaster? (circle one):		Yes No Undetermined Declined
If yes, did Disaster Survivor claim for the clothes with the insurance company? (circle one):		Yes No Undetermined Declined
Does Disaster Survivor/family have useable clothing and shoes for work or school? (circle one):		Yes No Undetermined Declined
Does Disaster Survivor/family have cold-weather clothing (e.g. coats, hats, gloves)? (circle one):		Yes No Undetermined Declined
Does the Disaster Survivor currently have a need for child care? (circle one):		Yes No Undetermined Declined
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Assistance with FEMA ONA Clothing - Other Laundry Assistance Voucher	Assistance with insurance claim/ appeal Clothing and Other Personal Items Referral to faith-based/ community organization for clothing
Notes:

Employment Assessment

Pre-Disaster Employment Assessment
Assessment Date:
Employed? (circle one):	Yes No Undetermined Declined
If yes, hours worked last week (write here):
If yes, Employment Tenure (circle one):	Don’t Know Permanent Refused Seasonal Temporary
Looking for additional employment/increased hours? (circle one):	Yes No Undetermined Declined
Post-Disaster Employment Assessment
Assessment Date:
Did you lose your job because of the disaster? (circle one):		Yes No Undetermined Declined
Employed? (circle one):		Yes No Undetermined Declined
If yes, hours worked last week (write here):
If yes, Employment Tenure (circle one):		Yes No Undetermined Declined
Looking for additional employment/increased hours? (circle one):		Yes No Undetermined Declined
Has Disaster Survivor applied for Disaster Unemployment Assistance? (circle one):		Yes No Undetermined Declined
If yes, was Disaster Unemployment Assistance approved? (circle one):		Yes No Undetermined Declined
If yes, was Disaster Unemployment Assistance denied? (circle one):		Yes No Undetermined Declined
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Education Employment Placement Service	Employment – Other Job Hunting Resources
Notes:

Financial Assessment

Family Financial Evaluation
Evaluation Date:			Monthly Income Total:		Annual Income Total:					Family Size:
Pre-Disaster Financial Assessment
Assessment Date (Pre):			Income Received? (circle one):			Yes No Undetermined Declined
Income Group (circle one):						Cash Income Non-cash Benefits
If Income or Non-cash Benefits received, enter income (dollar amounts)
Earned income (i.e. employment income):					Unemployment Insurance:
Supplemental Security Income (SSI):					Social Security Disability Income (SSDI):
Veterans Disability Payment:
Expenses
Rent:					Mortgage:
Maintenance:					Car Payment:
Car Insurance:					Gasoline:
Medical:					Food:
Miscellaneous:					Number of Expenses (enter count of expenses):
Total monthly amount:
Post-Disaster Financial Assessment
Assessment Date (Post):		Did you lose your employment because of the disaster? (circle one):							Yes No Undetermined Declined
Income Received? (circle one):	Yes No Undetermined Declined				Income Group (circle one):			Cash Income Non-cash Benefits
If Income or Non-cash Benefits received, enter income (dollar amounts)
Earned income (i.e. employment income):					Unemployment Insurance:
Supplemental Security Income (SSI):					Social Security Disability Income (SSDI):
Veterans Disability Payment:
Expenses
Rent:					Mortgage:
Maintenance:					Car Payment:
Car Insurance:					Gasoline:
Medical:					Food:
Miscellaneous:					Number of Expenses (enter count of expenses):
Total monthly amount:
Disaster Unemployment Assistance received? (circle one):					Yes No Undetermined Declined
If yes, amount (write here):					If yes, duration (start and end dates):
Referral Needed? (circle one):					Yes No Undetermined Declined
Referral Services (circle as many as apply):
Disaster Unemployment Assistance				Financial – Other			Grant Assistance
Notes:

Food Assessment

Assessment Date:
Does Disaster Survivor have enough food to feed all members of the household? (circle one):		Yes No Undetermined Declined
Pre-Disaster, was Disaster Survivor or any household member receiving food assistance? (circle as many as apply):
Assistance from local food pantries/food banks Other Women Infants & Children (WIC) Benefits	Meals on Wheels Supplemental Nutrition Assistance Program (SNAP)
Other Food Assistance (write here):
Since the disaster, has the Disaster Survivor requested help with food from anyone? (circle one):		Yes No Undetermined Declined
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Assistance with D-SNAP application Food Bank/Pantry Referral to community organizations for food needs Referral to Senior Meals on Wheels Services		Food – Other Food Delivery Services Referral to mass care assistance for immediate food needs Social Services for WIC/ SNAP/ D-SNAP
Notes:

Furniture and Appliances Assessment

Assessment Date:
Did Disaster Survivor have furniture or home appliances destroyed in the disaster? (circle one):		Yes No Undetermined Declined
If yes, did Disaster Survivor place a claim for the furniture and appliance with their insurance? (circle one):		Yes No Undetermined Declined
If yes, did Disaster Survivor get replacement items from any nonprofit organizations? (circle one):		Yes No Undetermined Declined
If yes, was Disaster Survivor able to install replacement furniture and appliances in the home? (circle one):		Yes No Undetermined Declined
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Appliances Assistance with install of new or removal of old appliances Furniture and Appliances - Other	Assistance with FEMA ONA Assistance with insurance claim/ appeal Referral to faith based/ community organization for replacement
Notes:

Health Insurance and Access to Health Care Assessment

Assessment Date:
Do you have health insurance? (circle one):		Yes No Undetermined Declined
If yes, Insurance Type? (circle one):
ACA Medicare Other Public S-Chip	Medicaid Military Insurance Private State Children’s Health Insurance Program S-Chip
Was this insurance lost as a result of the disaster? (circle one):		Yes No Undetermined Declined
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Cal 911 Durable medical equipment (e.g. wheelchair, cane) Health – Other Medical Equipment	Clinic Referral Emergency Medical, Health Insurance Related Medical care Medication
Notes:

Housing Assessment (page 1 of 2)

Assessment Date:
Where did the Disaster Survivor live pre-disaster? (circle one):
Apartment or house that you own Staying or living in a family member’s room, apartment, or house Community Transitional Housing Nursing or Assisting Living Facility Retirement Community Place not meant for habitation Undetermined		Room, Apartment, or house that you rent Community Shelter Public Housing Hospital Hotel or motel Other Declined
In the disaster, was Disaster Survivor home damaged or affected? (circle one):			Yes No Undetermined Declined
Is the Disaster Survivor able to access the home? (circle one):			Yes No Undetermined Declined
Does Disaster Survivor consider home livable or inhabitable? (circle one):			Yes No Undetermined Declined
Referral Needed? (circle one):			Yes No Undetermined Declined
Disaster Survivor Damage Rating (circle one):
Affected Major Other	Destroyed Minor Undetermined			Inaccessible No Damage Declined
Was Disaster Survivor relocated/evacuated? (circle one):			Yes No Undetermined Declined
If yes, what are Disaster Survivor’s plans to return home? (write here):
Do all of Disaster Survivor’s utilities work? (circle one):			Yes No Undetermined Declined
If no, which utilities are not working? (circle as many as apply):
Electrical power Internet access Sewer and sanitation	Fuel oil Phone Steam heat			Gas Propane Water
Details of Disaster Impacts to Home (write here):
Pre-disaster housing insurance status (circle one):
Disaster Survivor does not know insurance status Disaster Survivor owned home and had homeowner’s insurance Disaster Survivor was insured but does not have insurance policy information Lack of appropriate Insurance Coverage		Disaster Survivor had hazard-specific insurance for disaster type (flood, fire, earthquake) Disaster Survivor rented home and had renter’s insurance Disaster Survivor was uninsured
Details of insurance information (write here):

Housing Assessment (page 2 of 2)

Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Assistance Housing Reservation (ARC) Emergency Housing Mass Care Shelter Housing – Other Other Emergency Housing Tarp/ Blue Roof Utility, Housing	Debris Removal, Housing Repairs FEMA – Transitional Shelter Assistance (TSA) Muck and Gut, Well Repair Storage Temporary Housing, Basic Needs Water, Power Heat Shelter
Notes:

Transportation Assessment

Assessment Date:
What was the Disaster Survivor’s primary mode of transportation prior to the disaster? (circle one):
Bike Other Privately owned vehicle or motorcycle Ride with friends/family	Carshare Paratransit Public Transit Walk
If privately owned vehicle/motorcycle, is this method of transportation still working post-disaster? (circle one):		Yes No Undetermined Declined
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Bus Pass Gas Transportation – Other	Bus Tokens Transportation
Notes:

Senior Services Assessment

Assessment Date:
Prior to the disaster, was anyone in the household living in senior housing, assisted living, or in a nursing home? (circle one):		Yes No Undetermined Declined
If yes, was the Disaster Survivor displaced following the disaster? (circle one):		Yes No Undetermined Declined
If yes, please explain the circumstances (write here):
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Assistance with accessing VA benefits Home delivered meals (e.g., Meals on Wheels) Referral to area agency on aging	Assistance with LIHEAP application Referral to Adult Day Health Care Center Referral to senior center
Notes:

Legal Services Assessment

Assessment Date:
Referral Needed? (circle one):		Yes No Undetermined Declined
Referral Services (circle as many as apply):
Other Legal Service Referral to Legal Aid	Referral to Disaster Legal Services Program
Notes:

Behavioral Health Referral

Referral Service (circle one):
Behavioral Health – Other Crisis Counseling Program		Community clinical provider Disaster Distress Helpline		Counseling Services Private Counsel Directory
Target Completion Date:
Refer to Resource (write here):
Appointment Date:			Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result			Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet			No Show Service Provided Met- uninterested/refused Unmet- resources not available

Child Referral

Referral Service (circle one):
Case Manager Advocacy Head Start/ Early Head Start Referral to Social Services for TANF/CCDF application Social Services or Family Court for child support payments		Child – Other Referral to Child Care and referral agency Referral to VOAD/community group for school supplies			Childcare Referral to Disaster Distress Helpline School District
Target Completion Date:
Refer to Resource (write here):
Appointment Date:			Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result			Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet			No Show Service Provided Met- uninterested/refused Unmet- resources not available

FEMA/SBA Referral

Referral Service (circle one):
Assist with appeal for SBA denial Assist with completion of FEMA ONA Application Assist with FEMA IA denial Case Manager Assistance Obtain signed FEMA Disclosure release from Disaster Survivor Submit inquiry to FEMA IA Branch re: Disaster Survivor’s IA		Assist with completion of FEMA IA Application Assist with completion of SBA Loan Applications Assist with FEMA/SBA Sequence of Delivery FEMA – Other Provide education regarding FEMA/SBA Sequence of Delivery Submit inquiry to FEMA IA Branch re: Disaster Survivor’s ONA
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Clothing Referral

Referral Service (circle one):
Assistance with FEMA ONA Clothing – Other Laundry Assistance Voucher		Assistance with insurance claim/ appeal Clothing and Other Personal Items Referral to faith-based/ community organization for clothing
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Employment Referral

Referral Service (circle one):
Education Employment Placement Service		Employment – Other Job Hunting Resources
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Financial Referral

Referral Service (circle one):
Disaster Unemployment Assistance Grant Assistance		Financial – Other
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Food Referral

Referral Service (circle one):
Assistance with D-SNAP application Food Bank/Pantry Referral to community organizations for food needs Referred to Senior Meals on Wheels Services		Food – Other Food Delivery Services Referral to mass care assistance for immediate food needs Social Services for WIC/ SNAP/ D-SNAP
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Furniture and Appliances Referral

Referral Service (circle one):
Appliances Assistance with install of new or removal of old appliances Furniture and Appliances – Other		Assistance with FEMA ONA Assistance with insurance claim/ appeal Referral to faith-based/ community organization for replacement
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Health Referral

Referral Service (circle one):
Call 911 Durable Medical Equipment (e.g. wheelchair, cane) Health – Other Medical Equipment		Clinic Referral Emergency Medical, Health Insurance Related Medical Care Medication
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Housing Referral

Referral Service (circle one):
Assistance Housing Reservation (ARC) Emergency Housing Mass Care Shelter Housing – Other Other Emergency Housing Tarp/ Blue Roof Utility, Housing		Debris Removal, Housing Repairs FEMA – Transitional Shelter Assistance (TSA) Muck and Gut, Well Repair Storage Temporary Housing, Basic Needs Water, Power Heat
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Transportation Referral

Referral Service (circle one):
Bus Pass Gas Transportation – Other		Bus Tokens Transportation
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Senior Services Referral

Referral Service (circle one):
Assistance with accessing VA benefits Home delivered meals (e.g., Meals on Wheels) Referral to area agency on aging		Assistance with LIHEAP application Referral to Adult Day Health Care Center Referral to senior center
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Legal Services Referral

Referral Service (circle one):
Other Legal Service Referral to Legal Aid		Referral to Disaster Legal Services Program
Target Completion Date:
Refer to Resource (write here):
Appointment Date:		Appointment Time:
Comments
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Comment Date:	Comment:
Referral Result		Referral Result Date:
Result (circle one):
Information Only Rejected Met- service rendered Unmet		No Show Service Provided Met- uninterested/refused Unmet- resources not available

Record Notes

Entry Date:
Purpose (circle one): General Note FEMA Tier Change Close Record
Entry Date:
Purpose (circle one): General Note FEMA Tier Change Close Record
Entry Date:
Purpose (circle one): General Note FEMA Tier Change Close Record
Entry Date:
Purpose (circle one): General Note FEMA Tier Change Close Record
Entry Date:
Purpose (circle one): General Note FEMA Tier Change Close Record
Entry Date:
Purpose (circle one): General Note FEMA Tier Change Close Record

Recovery Plan

Name	Address	Email	Phone Number	Secondary Phone	FEMA Registration #
IDCM Worker	DR- Disaster Declaration	Disaster Survivor ID	CM Phone #	Disaster Survivor Plan Creation Date	IDCM Site Address

___________________________________________________________ ____________________________

IDCM Worker Signature Date and Time

___________________________________________________________ ____________________________

Disaster Survivor Signature Date and Time

IMPORTANT: Attach copies of all Disaster Survivor referrals and any other information relevant to Recovery Plan.

OMB Control No: 0970-0461 Expiration date: XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to support ACF/OHSEPR’s goal to quickly identify critical gaps, resources, needs, and services to support State, local and non-profit capacity for disaster case management and to augment and build human service capacity where none exists. Public reporting burden for this collection of information is estimated to average 1 hour per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information but is necessary to provide individual assistance during mission assignments as requested by the Federal Emergency Management Authority (FEMA). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact William Bolduc, Office of Human Service Emergency Preparedness and Response, Administration for Children & Families at [email protected]