Welcome

Introduction

Impacted by the recent disaster?

Please fill out this two-step survey to help assess the level of impact after a disaster and share your needs with local non-profits and/or local government. Your participation will allow us to advocate for more resources for our community and strengthen recovery efforts. This isn’t an application for assistance, but you can opt-in to receive text messages about available new resources and assistance as they become available.

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Yes

Prefilled Survey Id

Prefilled Contact Id

[HID]Survey Event Name

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Primary Household Member Information

First Name

Last Name

Phone Number

Email (optional)

We strongly encourage you to provide your email address or that of a trusted friend or family member.

Preferred Method of Contact

Alternative Phone Number

Address Search

Please type your street address and city, and then click on the matching result. Please do not include apartment numbers or unit numbers.

Were you able to find you address on the map?

YesNo, I couldn't find my address and I would like to enter my address manually

Street Address

Unit or Apartment #

City

State

Zip Code

County

What is the primary language spoken at home?

If you selected "Other," please specify your preferred language below:

Household Members

Does anyone in the household self-identify as having a disability?

YesNo

Are any household members aged 65 years or older?

YesNo

Is there a veteran or active duty service member living in the household?

YesNo

Voluntary Repairs

Connective has partnered with the Voluntary Organizations Active in Disaster to help home homeowners receive assistance as soon as possible. Are you interested in receiving emergent home repairs from volunteers?

Yes

No

Please note: There is NO guarantee of service. If you consent, your information will be shared with available Volunteer Organizations.

Ineligible

We're sorry, this program is only open to homeowners at this time. Please subscribe to Connective Texts to receive information about other resources available at this time.

Please select all of the immediate assistance that you require:

Roof TarpingTree / Debris RemovalInterior FloodingMold

Consent & Release

1. May we share your information with other nonprofit organizations involved in disaster recovery efforts? Connective works in collaboration with other community-based nonprofit organizations to help residents in our community recovery.

By responding "Yes," you are agreeing to the following: I authorize Connective to share my information, including my name and address with other disaster relief and voluntary organizations in partnership with our organization in order to coordinate disaster relief assistance. I understand that my information will be shared with participating members of my county's Long-Term Recovery Committee in order to direct community resources. I understand that I may revoke this consent at any time by contacting Connective (info@connectivetx.org).

YesNo

2. Would you like us to share your information with local government entities responding to disasters in your area? This information would be used to coordinate response efforts and to advocate for more resources for our community. If you are uncomfortable with us sharing individual level data with government entities, please respond no, in which case, we will only do so with nonprofit agencies (if you selected 'Yes' on the previous consent statement)

YesNo

3. Would you like us to share your information with the Federal Emergency Management Agency (FEMA)? FEMA manages financial assistance programs after disasters that may be able to help you recover more quickly. This information would be used to help them direct resources. If you are uncomfortable with us sharing individual level data with government entities, please respond no.

YesNo

4. Are you interested in receiving text notifications about local, free resources and services in our area?
Connective Texts is a free service that sends subscribers 2–3 texts with local resources per week.

Disclosures:

You will receive up to 10 text messages/month from Connective related to nonprofit and government resources.
You confirm that you are the subscriber to the relevant phone number or that you are the customary user of that number on a family or business plan and that you are authorized to Opt In.
Message & data rates may apply.
You can opt-out at any time by replying “STOP” to the text messages you receive.
You can adjust my subscription settings by replying "HELP" to the text messages you receive.
You will be texted a reminder of instructions for opting out of text messages at least once a month.
Your phone number will not be shared with any other organization without your explicit consent.

If you agree to receive text messages as described above, please click "Yes" below.

Yes, send me texts with local resourcesNo, I do not want to receive these notifications

Next Survey

Do you have time to answer a few more questions about your household and needs right now? It will only take 5-10 minutes.

Yes

No

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Survey Initiation

Are you filling out this survey on behalf of someone else?

YesNo

If you are filling out this survey out on behalf of someone else, please select the option that best describes you:

Please select the name of the organization you represent or are volunteering with:

Please write the name of the organization or group you represent or are volunteering with:

How did you hear about Connective Disaster Survey?

If you selected 'Other', please specify where you heard about this survey:

If you were referred to Connective Disaster Survey by a non-profit or faith-based organization, please type the name of that organization:

Single-family home	Apartment	Mobile home
Duplex/fourplex	Condo	Townhome

Less than $20,000	$20,000 to $34,999
$35,000 to $49,999	$50,000 to $74,999
$75,000 to $99,999	Over $100,000
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