June 2010 Disaster Survey
Exit this survey
1. CRST June 2010 Disaster Survey
1
. Name:
Name:
2
. Location:
Location:
3
. Phone Number
Phone Number
4
. Type of house
Type of house
Tribal
Private
HUD
Other
Other (please specify)
5
. Brand of House
Brand of House
6
. Do You Rent or Own your Home?
Do You Rent or Own your Home?
Rent
Own
7
. Do You Have
Percentage
Power
below 10%
50-100%
Do You Have Power Percentage
Water
below 10%
50-100%
Water Percentage
Fuel
below 10%
50-100%
Fuel Percentage
8
. Do you need ?
Do you need ?
Water
Food
Shelter
Temp Housing
Medical
Clothing
Damages or other comments
Powered by
SurveyMonkey
Create your own
free online survey
now!
Javascript is required for this site to function, please enable.