Hurricane Ida Disaster Recovery Assessment

OFFICE OF WORKFORCE DEVELOPMENT HURRICANE IDA DISASTER RECOVERY ASSESSMENT

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COMPLETE & SUBMIT FORM

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AN URBAN LEAGUE TEAM MEMBER WILL CALL YOU WITHIN 48 BUSINESS HOURS.

Today's Date:

Salutation

First Name

Last Name

Suffix:

Address:

Apt./Ste:

City:

State:

Zip Code:

Phone

Race:

Ethnicity:

Gender:

Gender Self Description   :
Current Age:

Email

Name of your emergency contact:

Emergency Contact No.:

Are you employed:

Name of Current Employer/Company:

Job Title:

Do you receive unemployment benefits?:

Are you a student:

Current Student Classification:

What School Do You Attend:

Were you impacted by a Disaster?:

Which Disaster Impacted your household:

Condition of Home:

Do you have sufficient consumer goods?:

Please select the consumer goods needed:

Other consumer goods needed:

List of Home Goods Needed:

Furniture Needed:

Appliances Needed:

# of School age youth in the household?:

Do you have access to a computer:

Do you have access to the Internet?:

Lacks consistent reliable transportation:

Applicant Shoe Size:

Applicant Pants Size:

Applicant Shirt Size:

Insurance Coverage:

# In Family indicated on FEMA App.:

FEMA/SBA Application Status:

Please provide FEMA Registration Number:

Please provide SBA Application Number:

Where are you living?:

Evacuation Address:

Evacuation City:

Evacuation State:

Evacuation Zip Code:

Affiliation with the Urban League: