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First Relief Victim Assistance Questionnaire

Please complete this short form so our team can better understand your situation and connect you with the right resources.

All information is confidential and used only to assist you in your road to recovery.

Contact Information

Preferred method of contact
Phone
Text
Email
Best time to reach you
Time
HoursMinutes

Incident Details

Type of incident (Check all that apply):
Is the property currently safe to enter?
Yes
No
Has the property been secured or boarded up?
Yes
No
Has the power and water been shut off?
Yes
No

Occupants and Safety

Who lives at the property?
Was anyone injured in the incident?
Yes
No
Were any animals injured or displaced in the incident?
Yes
No
Do you currently have a safe place to stay?
Yes
No
If no, would you like assistance with temporary housing?
Yes
No

Insurance & Ownership

Do you have property insurance?
Yes
No
Unsure
Have you filed a claim yet?
Yes
No
Are you the property owner?
Yes
No

Immediate Needs

Please check all that apply so we can connect you with the right help:

Additional Information

How did you hear about 1st Relief?

Acknowledgment

By submitting this form, I understand that 1st Reliefis a nonprofit organization providing consultation, coordination, and resources to assist victims of disaster.

I authorize a representative to contact me regarding available assistance and next steps.

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Date
Month
Day
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