Administration for Children and Families Disaster Information Collection Form

Part 3: Grantee

Survey Flow

Standard: Intro (1 Question)

Block: Disaster Impacts to Your Service Delivery Location (15 Questions)

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Start of Block: Intro

OMB Control Number: 0970-0476

Expiration Date: 07/31/2025

Disaster Information Collection Form

This form is intended to capture disaster impacts to human services providers and the communities they serve to enable the Administration for Children and Families (ACF) to support communities and families in their response to and recovery from a range of crises and emergency situations. Following a disaster, ACF’s Office of Human Services Emergency Preparedness and Response (OHSEPR) coordinates across the Agency’s programs to facilitate and support a UNIFIED ACF response. It is estimated to take XX minutes to cumulatively complete each form.

The information gathered in this form is solely for informational purposes and will not influence current or future grant funding. Your responses will not affect your grant status, nor are they linked to any guarantee of future federal funding.

End of Block: Intro

Start of Block: Disaster Impacts to Your Service Delivery Location

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

What is the physical address of the facility impacted by a natural disaster?

• Street Address (1) __________________________________________________

• Apt, suite, etc (optional) (2) __________________________________________________

• City (3) __________________________________________________

• State (4) __________________________________________________

• Zip Code (5) __________________________________________________

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

Extent of Damage Please estimate the extent of damage caused to the facility.

• No Visible Damage The facility has not been damaged and continues to operate (1)

• Inaccessible Cannot be reached for assessment (2)

• Affected: Cosmetic damage only Ex: Shingles and/or siding missing, one of two broken windows, damage to non-living spaces/structures (fence, garage, carports, porches/screened rooms), some damage on the property but not inside the facility.  (4)

• Minor: The damage is repairable and non-structural Ex. The facility may require some minor repairs. Large portions of roofing material and/or siding were damaged, several broken windows, minor damage inside the facility.  (5)

• Major: Significant structural damage. Extensive repairs are needed to make the facility operational again  Ex. Portions of the roof and/or walls are missing or breached by trees, debris, etc., major shifting or settling of the foundation, significant damage inside the facility (6)

• Destroyed: Facility is a total loss and is beyond repair Ex. Total collapse of facility or facility has shifted off foundation, catastrophic damage to the inside of the facility  (7)

• Other: Other damages on the property but not direct damage to the facility Ex. Downed power lines, uprooting of trees, vehicle damages, power outages, outdoor equipment/structures (8)

Skip To: QID14 If Extent of Damage Please estimate the extent of damage caused to the facility. = <strong>No Visible Damage</strong> The facility has not been damaged and continues to operate

Skip To: QID14 If Extent of Damage Please estimate the extent of damage caused to the facility. = <strong>Inaccessible</strong> Cannot be reached for assessment

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

What is the facility type that has been impacted by a natural disaster? 

• Non-Residential Building (2)

• Residential Building (1)

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

Are any of the following public utilities non-functional?

• No Electricity (1)

• No Natural Gas (3)

• No Running Water (2)

• All public facilities are in working order (4)

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

Have any of the following been damaged due to the disaster?

• None. (1)

• Building Structure exterior walls, roof condition, foundation integrity, windows and doors (5)

• Furniture and Equipment classroom furniture (desks, chairs, shelves), kitchen appliances, office equipment (computers/printers), storage units (13)

• Hazardous Materials mold or mildew presence, asbestos, lead paint, hazardous waste, or chemicals (16)

• Interior Facilities classroom spaces, flooring and carpets, ceiling and walls, bathroom fixtures and plumbing (10)

• Outdoor Spaces playground structures and equipment, parking lot and pavement, landscaping, drainage and water management (15)

• Safety and Security security systems, fencing, and gate condition (12)

• Supplies and Materials essential records and documents (18)

• Technology and Communication telephone and communication devices, audio-visual equipment - projectors, smart boards (14)

• Transportation Vehicles bus condition (tires, engine, seats), safety equipment (seat belts, fire extinguishers), maintenance records (17)

• Utilities and Systems electrical systems, HVAC systems (heating, ventilation, air conditioning), exterior plumbing (pipes, faucets, drains), water supply and quality, fire alarms and sprinkler systems (11)

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

Have all staff members reported they are safe at this facility? 

• No (1)

• Yes (2)

Display This Question:

If Have all staff members reported they are safe at this facility?  = No

And If

Loop all: Would you like to report another facility affected by the natural disaster? != No

How many staff members are no longer reporting to work due to the impacts of the disaster (if known)?

• 1-4 (1)

• 5-19 (2)

• 20-98 (3)

• 99+ (4)

• I do not know (5)

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

What types of program services are offered at this facility? Please select all that apply. 

• Behavioral Health (11)

• Case Management (10)

• Child Care (2)

• Disability Integration (12)

• Early Child Development (1)

• Elder Care (13)

• Emergency Shelter (7)

• Home Meal Delivery (6)

• Job and Vocational Training (4)

• LIHEAP (9)

• Nutrition Assistance (5)

• TANF (3)

• Transitional Shelter (8)

• Other (14)

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

To what extent has the disaster impacted your ability to provide program services?

• All services have been disrupted (1)

• Significant disruptions have occurred, affecting the availability of several services (2)

• Somewhat disrupted (3)

• Minor disruptions have occurred, but most services are still available (4)

• No Services have been disrupted at all (5)

Display This Question:

If To what extent has the disaster impacted your ability to provide program services? = All services have been disrupted

Or To what extent has the disaster impacted your ability to provide program services? = All services have been disrupted

Or To what extent has the disaster impacted your ability to provide program services? = Significant disruptions have occurred, affecting the availability of several services

Or To what extent has the disaster impacted your ability to provide program services? = Somewhat disrupted

Or To what extent has the disaster impacted your ability to provide program services? = Minor disruptions have occurred, but most services are still available

And If

Loop all: Would you like to report another facility affected by the natural disaster? = No

When do you estimate the facility will be able to resume program service operations?

• 0-1 Months (1)

• 1-3 Months (2)

• 3+ Months (3)

• I do not know (4)

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

How many people did this facility typically serve each month before the disaster? Please select a range below. 

• 0-25 (1)

• 26-50 (26)

• 51-75 (27)

• 76-100 (28)

• 101-125 (33)

• 126-150 (34)

• I do not know (37)

• Other (39) __________________________________________________

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

If known, are there people you serve who have been relocated?

• No (1)

• Yes (2)

Display This Question:

If If known, are there people you serve who have been relocated? = Yes

And If

Loop all: Would you like to report another facility affected by the natural disaster? != No

If known, where have they relocated outside of your service area? 

• Outside of the neighborhood (6)

• Outside of the city (4)

• Outside of the state (5)

• I do not know (7)

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

Do you have any additional details about the natural disaster's impacts to share with ACF? If so, please provide them here.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Display This Question:

If Loop all: Would you like to report another facility affected by the natural disaster? != No

Q20 Would you like to report another facility affected by the natural disaster?

• Yes (1)

• No (2)

End of Block: Disaster Impacts to Your Service Delivery Location

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