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Note: Completing this questionnaire helps determine applicant eligibility but does not guarantee assistance.

DisasterAssistance.gov - Access to Disaster Help and Resources
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The questionnaire below is for OTHER current disaster events - NOT for the Gulf Oil Spill.
For more information on oil spill assistance, please click the “Affected by the Gulf Oil Spill?” banner located above.

Complete this anonymous questionnaire to obtain the most accurate list of assistance programs for which you may be eligible. The following questions are directly related to disaster assistance. Please answer them to the best of your ability or skip if not applicable.
1. As a result of this disaster, are you in need of assistance in any of the following categories? (select all that apply)
  Employment
Financial
Food
Housing
Legal
Medical
2. What describes your housing/living situation prior to the disaster? (select all that apply)
  Rent
Own
Rural
3. Has your home flooded as a result of this disaster?
  Yes
No
No Answer
4. Have you or a member of your household experienced life-changing events as a result of this disaster? (select all that apply)
  Permanent disability
Death of a current spouse, parent, or child
Death of a former spouse
Death of a disabled spouse
Temporary or permanent relocation that resulted in an address change
5. Are you or a member of your household a: (select all that apply)
  Business owner
Current or former member of the military
Farmer
Federal retiree
Over 50 years of age
Survivor of a Public safety officer who died in the line of duty
Retiree
Student or recipient of a Federal Student Loan
Widow(er)
World War II Veteran
6. Are you or a member of your household receiving government assistance or benefits (for example, Housing Choice Voucher Program (Section 8) assistance, Social Security benefits, etc.)?
  Yes
No
No Answer
7. Are you or one of your direct dependents a U.S. citizen or a non-citizen with eligible immigration status?
  Yes
No
No Answer
8. Are you or a member of your household enrolled in a federally recognized American Indian Tribe or Alaska Native Tribe?
  Yes
No
No Answer
9. At the time of the disaster, of what state, territory, or tribal land were you a primary, legal resident?
 
10. Was this disaster a result of a terrorist act that occurred outside of the United States?
  Yes
No
No Answer
11. Are you a victim of a crime that occurred during the disaster or in the period immediately following a disaster?
  Yes
No
No Answer
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