North Complex West Fire Needs Assessment Survey

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Para completar este formulario en Español: www.shorturl.at/ouwDQ

Please complete this North Complex West Fire Needs Assessment Survey. This will help our recovery organizations assist the needs in our community. Please read the following so that you understand the limitations of this form and the limitations on resources.

- This information is confidential and will not be shared without your consent.
- Filling out this form does not guarantee access to disaster case management or recovery resources.
- Certain documentation from you may be requested later to confirm eligibility for specific recovery programs.
- In response to this form, you may receive communications from local disaster recovery agencies by text, phone, or email. Please be sure to check your messages frequently.
- If you have already completed this form, you do not need to fill it out again.
- Only submit an update to this form if you have a change in your contact information: phone number, email address, physical address.

I understand that by filling out this form, it does not guarantee access to disaster case management or recovery resources.

Yes

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First Name *

Last Name *

Best Phone Number *

2nd Phone Number

Email Address

Gender *

Date of Birth *

What is the best way to reach you? *

E-mail

Phone

What is the best time to contact you?

Morning 7:30am to 12 Noon.

After 12 Noon to 6:00 pm.

Saturdays

Anytime.

Do you consent for your information to be shared with other agencies such as disaster case management services and financial assistance programs to help North Complex West Survivors meet their immediate and long term needs? (Such as Caring Choices, United Way, Youth for Change, Northern Valley Catholic Social Services, the Jesus Center, Tzu Chi, St. Vincent de Paul, North Valley Community Foundation, Boys & Girls Club of Northern California, Red Cross and others, as well as the Butte County Department of Employment and Social Services). I understand that filling out this form does not guarantee access to disaster case management or recovery resources. *

I consent.

I do not consent. (Please note that consent is required for your information to be shared with agencies providing disaster case management and financial assistance.)

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