Family Fire Survey Question Title * 1. How were you affected by the Woolsey Fire incident (check all that apply)? No impact Housed evacuees Evacuated for ____ days (answer in "other" box below) Major damage to neighborhood Major damage to home Home destroyed Have not been able to get home to assess the damage Family members/loved ones suffered losses Other (this is also a place to specify how many days you have been/were evacuated): OK Question Title * 2. Will you be dislocated from your home on or after Friday, November 16? Yes No OK Question Title * 3. If yes, approximately how far away from school will you be? 1-5 miles 6-10 miles 11-15 miles 16-20 miles 21 miles or more OK Question Title * 4. Do you plan to attend school between now and the Thanksgiving holiday? Yes, some or all days No Not sure OK Question Title * 5. Do you need assistance with transportation for your child at this time (even if your child is not currently a bus rider)? Yes No OK Question Title * 6. For how long do you expect to be dislocated from your home? A few days A few weeks A month Several months An indefinite period of time OK Question Title * 7. If you are currently in your home, do you have power? Yes No I am not in my home OK Question Title * 8. If you are currently in your home, do you have water? Yes No I am not in my home OK Question Title * 9. If you are currently in your home, do you have gas? Yes No I am not in my home OK Question Title * 10. If you are currently in your home, do you have internet connectivity? Yes No I am not in my home OK Question Title * 11. What reactions or emotions should we be aware of that your child(ren) is (are) experiencing? Will your child(ren) need extra emotional support at school? OK Question Title * 12. Please share any needs you have or ways Viewpoint can be helpful to you. OK Question Title * 13. What is your name? OK DONE