1 Disaster Human Services Case Management Intake Assessmen

O MB Control No:

Expiration Date:
Estimated Burden: 75 to 90 Minutes

Disaster Human Services Case Management Intake Assessment

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to enable ACF/OHSEPR to identify a disaster survivor’s unmet needs and provide case management support that can connect a disaster survivor to services that meet their needs. Public reporting burden for this collection of information is estimated to average 75 to 90 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is XXXX-XXXX and the expiration date is XX/XX/20XX. If you have any comments on this collection of information, please contact the Office of Human Services Emergency Preparedness and Response, 330 C St. SW, Washington, D.C. 20201.

Section I. Disaster Survivor Information
Last Name		First Name					Middle Name
Home Phone		Mobile Phone					Email Address
Primary Address (Street, City, State, Zip Code)				☐Own ☐Rent			Was your home damaged by the disaster? ☐Yes ☐ No
Current Address, if different from your answer to question 7 (Street, City, State, Zip Code)
Were you unhoused before the disaster? ☐Yes ☐ No		If you were unhoused, please describe the general area where you lived before the disaster:
Privacy Act Statement: I authorize the HHS Administration for Children and Families (ACF) Office of Human Services Emergency Preparedness and Response (OHSEPR) and its agents to collect my personal identifiable information (PII) and to disclose my PII to other ACF program offices and state, tribal, and territorial human services grantees, service providers, contractors, or private organizations, to support my disaster-caused unmet needs via case management. Providing this information is voluntary, however refusal to do so will mean HHS may be unable to provide me assistance.
Signature		Date
Section II. Demographic Information
What is your race? Select all that apply ☐American Indian / Alaska Native ☐Black / African American ☐Asian ☐Native Hawaiian ☐Pacific Islander ☐White ☐Other ☐Declined to answer What is your ethnicity? ☐Hispanic or Latino ☐Non-Hispanic ☐Declined to answer		What is your preferred language? ☐Arabic ☐Chamorro ☐Chinese – Cantonese ☐Chinese – Mandarin ☐English ☐Farsi ☐French ☐German ☐Haitian Creole			☐ Italian ☐Japanese ☐Korean ☐Ōlelo Hawaiʻi  ☐Portuguese ☐ Russian ☐Samoan ☐Spanish ☐Tagalog ☐Vietnamese ☐Other ☐Declined to answer			What is your gender? ☐Male ☐Female ☐Non-binary / gender nonconforming ☐Other ☐Declined to answer What is your marital status? ☐Never Married ☐Married ☐Separated ☐Divorced ☐Widowed ☐Declined to answer
Are you a veteran? Yes☐ No ☐		If you answered yes to Question 19, please identify any veterans’ benefits received: ☐Disability compensation ☐Education and Training ☐Health care ☐Home loans ☐Pension
Do you have a disability? ☐Yes ☐No ☐Declined to answer		If you have a disability, please describe:
Section III. Household Information
How many people live in your household?		How many minors? Number Age 0 – 5: ___ Number Age 6 – 17: ___						How many adults? Number Age 18 – 26: ___ Number Age 27 – 54: ___ Number Age 55 – 84: ___ Number Age 85+: ___
Section IV. Needs Assessment
Documentation
Did you lose personal identification because of the disaster? Yes☐ No ☐ ☐Declined to answer		☐Birth certificate ☐Driver’s license ☐Green card ☐Military ID ☐ Passport ☐Social Security card ☐ Other:
Case Manager Notes:
Housing Needs
Do you have funds needed to repair your home? Yes ☐ No ☐			Have you applied for federal disaster assistance to repair the damage? Yes ☐ No ☐ If yes, ☐FEMA ☐SBA ☐Other:
Short Term Housing Status Answer questions 31 – 37 if you are no longer living in your home because of the disaster.
Where are you currently living? ☐In a friend or family member’s room, apartment, or house ☐Car ☐Community shelter ☐Community transitional housing ☐Hotel or motel ☐Tent ☐Other: ☐Declined to answer			Are all members of your household living there with you? ☐Yes ☐No ☐Declined to answer
			When did you start living there? How long can you continue to live there?
Have you ever felt unsafe or threatened in your current living situation? ☐ Yes ☐ No ☐Declined to answer			Do you need funding assistance to pay rent in your current location? ☐ Yes ☐ No
Do you need assistance to move to another location? ☐Yes ☐ No ☐Declined to answer
Longer-Term Housing Need
Please describe your current plan for longer-term housing:
Case Manager Notes:
Human Services Needs
Were you enrolled in or did you receive any State, Tribe, or Territorial administered human services benefits prior to the disaster? Select all that apply. ☐Child Care Subsidies ☐Rental Assistance ☐Workforce Development ☐Child Support Services ☐Supplemental Nutrition Assistance Program ☐Unemployment Assistance ☐Head Start ☐Supplemental Security Income ☐Other: ☐Home Energy Assistance ☐Supplemental Security Disability Income ☐Declined to answer ☐Medicaid ☐ Temporary Assistance for Needy Families ☐Medicare ☐Women, Infants, and Children
Children Needs
Are any children in your household currently attending child care? ☐Yes ☐No	If yes, are the children in your household receiving child care services from the same provider that they attended before the disaster? ☐Yes ☐No					If you answered yes to questions 40 and 41, select the child care program type: ☐Full-day programs ☐Partial day programs ☐Before school care ☐After school care
Are you experiencing challenges that prevent you from obtaining child care for your children? ☐Yes ☐No	Do you have children enrolled in K – 12 school? ☐Yes ☐No					If you answered yes to Question 44, are your children able to attend the school they attended before the disaster? ☐Yes ☐No
Are you aware of any situations where the children in your household may not be receiving the necessary attention and care that they need? ☐Yes ☐No ☐Declined to answer
Case Manager Notes:

Elder Care Needs

48. Are you currently receiving assistance or support to care for elders in your household?

☐Yes

☐No

49. Are you experiencing challenges that prevent you from obtaining care for the elders in your household?

☐Yes

☐No

☐Declined to answer

Case Manager Notes:

Employment and Financial Needs

50. Were you employed before the disaster?

☐Yes

☐No

☐Declined to answer

51. Did you lose your job because of the disaster?

☐Yes

☐No

☐Declined to answer

52. If you answered yes to Question 50, have you registered for state or federal disaster unemployment assistance programs? ☐Yes ☐No ☐Declined to answer

Please identify the programs:

53. If you are currently working, what type of work do you do?

54. Are you being paid for this work?

☐Yes

☐No

☐Declined to answer

55. Do you feel comfortable at your workplace?

☐Yes

☐No

☐Declined to answer

56. Do you have any other current income sources?

☐Yes

☐No

☐Declined to answer

Food Security

57. Did you lose food because of the disaster? ☐Yes ☐No ☐Declined to answer

58. Do you currently have access to routine meals? ☐Yes ☐No ☐Declined to answer

59. Do you have specific dietary needs that you are unable to meet? ☐Yes ☐No

Case Manager Notes:

Transportation Needs

60. What was your primary mode of transportation prior to the disaster? (Select all that apply)

☐Bike

☐Carshare

☐Privately owned vehicle

☐Paratransit

☐Public Transit

☐Ride with friends/family

☐Walking

☐Declined to answer

61. Are you still able to access these modes of transportation after the disaster? ☐Yes ☐No

Case Manager Notes:

Utility Needs

62. If you are living in your pre-disaster home, do you have utility service? ☐Yes ☐No ☐Declined to answer

63. Are you able to pay your utility bills following the disaster? ☐Yes ☐No ☐Declined to answer

64. Have you applied for home energy assistance programs to assist with utility bills? ☐Yes ☐No ☐Declined to answer

Case Manager Notes:

Health Needs

Behavioral Health

65. Do you have any concerns or anxieties that you are comfortable sharing?

☐Yes. Please describe.

☐No

☐Declined to answer

Description:

66. How are you coping with the disaster?

Description:

☐Declined to answer

67. Do you have a support network of friends/family you can rely on to help cope with stress? ☐Yes ☐No

68. How are the other adults in your household coping with the disaster?

☐Declined to answer

69. Do you have any concerns about controlling behaviors by people in your household?

☐Yes. Please describe.

☐No

☐Declined to answer

Notes:

70. Do you need a referral for behavioral health support? Select all that apply.

☐Behavioral health counselor

☐Child and adolescent psychiatry

☐Clinical psychologist

☐Clinical social worker

☐Disaster Distress Helpline

☐Family therapy

☐Pastoral/Faith-Based counseling

☐Substance abuse counseling

☐Other:

☐Declined to answer

Health Insurance and Access to Health Care

71. Do you have health insurance for yourself? ☐Yes ☐No ☐Declined to answer

If yes, select:

☐Affordable Care Act

☐Medicaid

☐Medicare

☐Military Insurance

☐Other Public

☐ Private Insurance

72. Do all members of your household have health insurance? ☐Yes ☐No ☐Declined to answer

If yes, select:

☐Affordable Care Act

☐Children’s Health Insurance Program (CHIP)

☐Medicaid

☐Medicare

☐Military Insurance

☐Other Public

☐Private Insurance

☐State Children’s Health Insurance Program (S-CHIP)

73. Do you have a primary care physician? ☐Yes ☐No ☐Declined to answer

74. Did you lose prescription medicines because of the disaster? ☐Yes ☐No ☐Declined to answer

75. Did you lose medical equipment or supplies because of the disaster? ☐Yes ☐No ☐Declined to answer

If yes, describe:

76. If you were receiving medical treatment before the disaster, are you still able to receive treatment?

☐Yes ☐No ☐Declined to answer

77. Do the members of your household have a primary care physician? ☐Yes ☐No ☐Declined to answer

78. If members of your household were receiving medical treatment before the disaster, are they still able to receive treatment? ☐Yes ☐No ☐Declined to answer

Case Manager Notes: