DISASTER RESPONSE SURVEY to assess the immediate impact of a disaster on an agency’s operations and capacity to provide services.

OMB Control Number: 2502-0615

Expiration Date:

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. The information collected will be used assess the operational status of housing counseling agencies after a disaster to determine needed assistance. This collection of information is voluntary. The agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number. Responses are protected from disclosure pursuant to the Privacy Act of 1974. HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012;31 U.S.C. 3729, 3802).

The Office of Housing Counseling (OHC) is monitoring the impact on your community and agency, due to a recent disaster. You and your agency may have been impacted by this disaster and our goal is to help support you. We know you and your agency are an important part of your community and its response and recovery. To help support you, your clients, and your community we are sending this initial response survey to assess the impact of the disaster on your agency’s operations and capacity to provide services.

Your response to this survey is voluntary.

Required questions are marked with an asterisk. All other questions are optional. Please provide information based on the current situation of your agency as it relates to the most recent disaster. Your survey responses will help OHC understand your current operating status and evaluate the needs of your agency and your clients.

Thank you for completing the initial OHC Disaster Response Survey. If you would like assistance, please contact your OHC POC or send an email to OHCDart@hud.gov.

Question Title

* 1. Name of Housing Counseling Agency

Question Title

* 2. Agency HCS ID Number

Question Title

* 3. Identify the federally declared disaster that has impacted the area your agency serves.

Name of Declaration

Date of Declaration

Question Title

* 4. Identify the local, state, or regional disaster that has impacted the area your agency serves.

Name of Declaration

Date of Declaration

Question Title

* 5. Disaster type (i.e. flood, fire, etc.)

Question Title

* 6. Who is the current contact for your agency? Please share their contact information.

Name

Title

City/Town

State

Zip Code

Email Address

Phone Number

Question Title

* 7. Select from the options below how the most recent disaster has impacted agency operations to provide housing counseling. Select all that apply.

Currently not providing services

Inoperable or damaged communication systems (phone or postal service)

Inoperable or damaged telecommunicatoin systems (internet, computer, or cellular)

Building was damaged or limitations with physical work space for staff and/or public

Building is closed to staff

Agency staff are teleworking

Agency staff are providing services offsite where disaster impacted clients are located

Building is closed to the public

Staff were impacted and have limited ability to provide services

Community infrastructure has been impacted (roads closed, limited community services, etc.)

Other (please specify)

None of the above

Question Title

* 8. Share the post-disaster needs of the agency, impacting its services. Select all that apply.

Training

Technical Assistance

Other (please specify)

None of the above

Question Title

* 9. Does your agency have a Continuity of Operations Plan (COOP). If so, please share any actions or protocols activated in response to the disaster.

We do have a COOP and it was activated.

We do have a COOP but it was not activated.

We do not have a COOP.

Narrative of actions triggered:

Question Title

* 10. Does the agency have an Emergency Response Plan? If so, please share any actions or protocols activated in response to the disaster.

We do have an Emergency Response Plan and it was activated.

We do have an Emergency Response Plan and it was not activated.

We do not have an Emergency Response Plan.

Narrative of actions triggered:

DISASTER RESPONSE SURVEY to assess the immediate impact of a disaster on an agency’s operations and capacity to provide services.

Question Title

* 1. Name of Housing Counseling Agency

Question Title

* 2. Agency HCS ID Number

Question Title

* 3. Identify the federally declared disaster that has impacted the area your agency serves.

Question Title

* 4. Identify the local, state, or regional disaster that has impacted the area your agency serves.

Question Title

* 5. Disaster type (i.e. flood, fire, etc.)

Question Title

* 6. Who is the current contact for your agency? Please share their contact information.

Question Title

* 7. Select from the options below how the most recent disaster has impacted agency operations to provide housing counseling. Select all that apply.

Question Title

* 8. Share the post-disaster needs of the agency, impacting its services. Select all that apply.

Question Title

* 9. Does your agency have a Continuity of Operations Plan (COOP). If so, please share any actions or protocols activated in response to the disaster.

Question Title

* 10. Does the agency have an Emergency Response Plan? If so, please share any actions or protocols activated in response to the disaster.

Question Title

* 11. Please share any other comments or observations.