Noble County Disaster Initial Intake/assessment Form printable pdf download

Noble County Disaster Initial Intake/Assessment Form

Head of Household Last Name: ___________________________ First Name: __________________________________

Spouse’s Name: __________________________________

Address of Damaged Home: _________________________________________________________________________

Is this your Primary Residence: __________

Are you Homeowner: _______ Landlord: _______

Renter: ________

If renter, Landlord Name: ________________________ Address: ____________________ Phone: ______________

Type of Home:

Single family home _________ Mobile home ______________

Modular home _____________

Income Property ___________ Apartment ________________

Duplex ___________________

Number of people in Home: ________

Adults: _______ Children: _______

Ages: _________________________

Elderly (over 65): _________ Disabled: _________ Single Parent: _______ Veteran: ___________

Ethnicity of household members: ________________________ Primary Language spoken:_______________________

Address Currently Residing/Staying At: ________________________________________________________________

Current Contact Numbers: ________________________

________________________

_____________________

Home

Cell

Work

Do you have:

Homeowner’s Ins. ________ Flood Ins. _______

Contents Ins. ______ Sewer Backup Ins. ________

Have you contacted agent ___________

Settlement _____________________________________

Have you applied for or received aid with any other agency/organization? ______ Whom: ______________________

For What:__________________________________________________ Amount: _______________________________

If Damage due to FLOODING:

Type of Home:

Slab (No basement or crawl space) ______ 1 or 2 story w/Basement or Crawl _________

Bi-level _________________

Tri-level ____________ Quad-level _________________

Is WATER DAMAGE in:

Basement only _______ Depth of water ________

Is basement Essential Living Space?______________

What type of living space: _________________________________________________

Crawl space only ____________

Depth of Water _________

Main living area of house ______

Depth of water ______

How many rooms affected: ___________

Foundation damage ________ HVAC Damage ________ Mold _________ Well _______ Septic ________

Noble County Initial Disaster Assessment-Intake Form/INVOAD/July 2017

Noble County Disaster Initial Intake/assessment Form

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