Form FEMA Form 009-0-42 FEMA Form 009-0-42 Survivor Sheltering Assessment Alternate Version

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Overview

PRA and Privacy Statements
Shelter Resident Data Form
FEMA Data Spreadsheet

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Sheet 1: PRA and Privacy Statements

Survivor Sheltering Assessment Tool - Alternate COVID
						OMB Control Number:		1660-0142
						Expiration Date:		31-May-22
PAPERWORK BURDEN DISCLOSURE NOTICE: FEMA Form 009-0-42AV
Public reporting burden for this data collection is estimated to average 10 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to obtain or retain benefits voluntary. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472-3100, Paperwork Reduction Project (1660-0143) NOTE: Do not send your completed form to this address.
PRIVACT ACT STATEMENT AUTHORITY: FEMA collects, uses, maintains, retrieves, and disseminates the records within this system under the authority of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act), Pub. L. No. 93-288, as amended (42 U.S.C. §§ 5121-5207); 6 U.S.C. §§ 776-77, 795; the Debt Collection Improvement Act of 1996, 31 U.S.C. §§ 3325(d), 7701(c)(1); the Government Performance and Results Act, Pub. L. No. 103-62, as amended; Reorganization Plan No. 3 of 1978; Executive Order 13411, “Improving Assistance for Disaster Victims,” August 29, 2006; and Executive Order 12862 “Setting Customer Service Standards,” September 11, 2003, as described in this notice. PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining eligibility and administrating financial assistance under a Presidentially-declared disaster. Additionally, information may be reviewed internally within FEMA for quality assurance purposes and used to assess FEMA's customer service to disaster assistance applicants. FEMA collects the social security number (SSN) to verify an applicant's identity and to prevent a duplication of benefits. ROUTINE USE(S): FEMA may share the personal information of U.S. citizens and lawful permanent residents contained in their disaster assistance files outside of FEMA as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, including pursuant to routine uses published in DHS/FEMA-008 Disaster Recovery Assistance Files Notice of System of Records, 78 Fed. Reg. 25,282 (Apr.30, 2013) and upon written request, by agreement or as required by law. FEMA may share the personal information of non-citizens, as described in the following Privacy Impact Assessments: DHS/FEMA/PIA-012(a) Disaster Assistance Improvement Plain (DAIP) (Nov. 16, 2012); DHS/FEMA/PIA-027 National Emergency Management Information System - Individual Assistance (NEMIS-IA) Web-based and Client-based Modules (June 29, 2012); DHS/FEMA/PIA-015 Quality Assurance Recording System (Aug. 15, 2014). FEMA may share your personal information with federal, state, tribal, local agencies and voluntary organizations to enable individuals to receive additional disaster assistance, to prevent duplicating your benefits, or for FEMA to recover disaster funds received erroneously, spent inappropriately, or through fraud. CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: The disclosure of information, including the SSN, on this form is voluntary; however, failure to provide the information requested may delay or prevent the individual from receiving disaster assistance.
Intent The purpose of this form is to help FEMA understand how best it can support survivors as they transition out of temporary shelters. No information given will be used to determine eligibility for assistance. Eligibility for assistance will only be determined through the separate registration process. It is estimated that this form will take 10 minutes to complete. Do you wish to continue?
I accept the privacy statement:					If Yes, please fill in the Form

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Sheet 2: Shelter Resident Data Form

Survivor Sheltering Assessment Tool - Alternate COVID FEMA Form 009-0-42AV
Shelter Resident Information for the Head of Household:
	FEMA Disaster Assistance Registration ID (if available)
	Shelter Name
	Shelter ID
	First Name
	Last Name
	Phone Number
	Damaged Dwelling Street Address
	Damaged Dwelling City
	Damaged Dwelling State
	Damaged Dwelling Zip
	Number of Individuals in Household

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Sheet 3: FEMA Data Spreadsheet

No.	FEMA Registration ID	Shelter Name	Shelter ID	Head of Household: First Name	Head of Household: Last Name	Head of Household: Phone Number (Enter With No Spacing)	Damaged Dwelling (DD): Street Address	Damaged Dwelling (DD): City	DD: State	DD: Zip Code	Number of Individuals in Household	Notes
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