Winter Storm Damage Assessment Triage Form

DRC

Section 1 - DAMAGED PROPERTY CONTACT INFORMATION

Last Name
First Name
Phone
Email
County
Damaged Property Address
Street Address
City
State
Zip
Temporary Mailing Address
Click here if same as Damaged:
Street Address
City
State
Zip
Have you been displaced?
What is your date of birth?
Household size?
Number of children under 18?
Do you have any medical needs? If so, please describe.
What is your race?
What is your gender?
If Different Identity, please specify:
What is your annual household income? $
Are you looking for assistance with your:
(select all that apply - Ctrl+Click)
If Other, please explain:
Do you own or rent the property?
If Other, please explain:
If you rent, is your landlord helping with repairs?
If Other, please explain:

Section 2A - PROPERTY OWNERS ONLY

If you are NOT a property owner, please skip to Section 2B.
How would you describe this property?
Pre-disaster estimated home value: $
Was the property used as a home business?
Does this property have flood insurance?
If yes, please answer the following questions:
Amount of coverage for real property? $
Amount of coverage for personal property? $

Section 2B - RENTERS ONLY

Do you have renters insurance?
Does your policy include Additional Living Expenses (ALE) coverage?

Section 3 - EVERYONE

*For assistance, please see Reference.
Have you been able to obtain copies of vital records that may have been
destroyed? (i.e., birth certificates, driver’s license, vehicle registrations, etc.)
(*Ref: DMV, Office of Vital Records)
Do you need support filling out insurance claims?
(*Ref: FEMA, SBA, CA State of Insurance)
Do you need help with Taxes?
(*Ref: Franchise Tax Board)
Will you have difficulty paying your deductible?
(*Ref: SBA, Community Based Orgs)
Are you able to clean up on your own?
(*Ref: Community Based Orgs)
Do you need assistance paying for cleanup supplies and materials?
(*Ref: Red Crosss, SBA, Community Based Orgs)
Do you need assistance with housing relocation?
(*Ref: Social Service, Cal OES)
If yes, for what duration?
Are you alone or isolated and would like to talk to someone?
(*Ref: Red Cross, Community Based Orgs)
Are you in need of food due to flood damage?
(*Ref: Red Cross, Food Bank, Community Based Orgs)
Are you unemployed or did you or someone in your household lose income as a result of the flooding?
(*Ref: EDD)
If yes, please explain:
Do you need financial assistance with your business?
(*Ref: SBA)
Do you need assistance with a farming Business?
(*Ref: USDA)
Are you a veteran?
(*Ref: Dept of Veteran Affairs)
What areas of your property were damaged in the flood?
If Other/Floor, please explain:
What is your greatest concern(s) at this time?
Do you want to be contacted by local Community Based Organizations with additional assistance and resources?

Section 4 - ROADWAY CONDITION

Has there been damage to your road?
If yes, please explain:
Is the road a City, County or Privately maintained road?
If County maintained road, resident should report the issue to Road Dispatch: 831.477.3999
If City of Watsonville maintained road, resident should report the issue to the City of Watsonville: 831.768.3133
If it is a CSA maintained road, resident should report the issue to the DPW/CSA: 831.454.2160
If it is a privately mainlined road, the Federal Emergency Management Administration (FEMA) and/or the U.S. Small Business Administration (SBA) may provide financial assistance for repairs needed to restore access to an owner’s, or group of owners’, primary residence(s).
Applied Date
CONSENT TO RELEASE INFORMATION
By consenting to this form, you authorize Santa Cruz County to share certain personal information collected about you or your family with other disaster relief and voluntary organizations participating in the Santa Cruz County Long Term Recovery Group. Members of the Santa Cruz County Long Term Recovery Group need to share this information in order to coordinate available disaster relief services and assistance, and to reduce the paperwork and applications necessary in order for you or your family to receive disaster relief assistance and services from multiple relief organizations. All disaster relief organizations participating in the Santa Cruz County Long Term Recovery Group are committed to respecting your privacy and using the information solely for the purpose of coordinating and providing disaster relief assistance. With the exception of certain limited circumstances, it is the policy of the Santa Cruz County Long Term Recovery Group not to release information about individual or family disaster relief assistance, or other personal information obtained through the provision of disaster relief services, without the written consent of the individual or family. Therefore, we need your consent to share this information to and assist you or your family with obtaining the disaster relief services in the most expeditious and least cumbersome manner.
By checking this box I am agreeing to allow this form to be shared with the Long Term Recovery Group, County of Santa Cruz, City of Watsonville, FEMA, CalOES, Community Bridges and Catholic Charities.