Dallas Snow Storm Needs Intake Form

The Jewish Federation, utilizing our Community Crisis Management Team infrastructure, is conducting an assessment of needs as a result of Winter Storms Uri and Viola. If you have been personally impacted by the storms and are in need of assistance, or know someone who has, please complete the form below. The responses are being monitored daily Monday - Friday, and needs will be triaged as resources are available. If you have a life-threatening need, please dial 911 or call your city's emergency number. A member of the Jewish Federation’s professional team will be in touch with any questions. Please note that we cannot guarantee the provision of goods or services.

**While efforts will be made to ensure that personal information is only shared as needed for the provision of goods, please note that information submitted through this form will be shared between agencies, staff, and volunteers to best-deploy limited resources that are available. Your submission of this form is an acknowledgment that you understand these limitations upon your privacy, that you voluntarily choose to participate and share your information, and that you agree to waive your legal privacy rights, including those under HIPAA.

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* 1. Please complete the following for the individual in need:

Name

Address

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 2. If you are completing the form on behalf of an individual, please provide your contact information.

Name

Address

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 3. What is the best way for us to contact you?

Phone

Text message

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* 4. Please share your affiliation with any of the local organizations below:

Jewish Federation of Greater Dallas

Aaron Family JCC

Jewish Family Service

The Legacy Senior Communities, Inc.

CHAI

Local synagogue (please indicate which one in the space below)

Day School (please indicate which one in the space below)

Please share the school and/or synagogue you attend.

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* 5. How many people reside in your home?

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* 6. Does anyone living in your home have special needs or medical issues?

Yes

Please explain:

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* 7. Do you have power and/or running water?

Yes, I have both

Yes, I have power only

Yes, I have water only

No, I do not have either

Please provide details on services currently received including how long you have been without power and/or water.

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* 8. Please select any additional challenges you are facing at this time:

Boil-water order

Food access

Other (please specify)

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* 9. Has your home been damaged by the storm?

Yes

If yes, please explain the damage incurred to-date.

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* 10. Do you need a plumber, electrician, or other professional services to repair your home? If yes, please describe the type of work needed.

Yes

Maybe

Please explain

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* 11. I am currently in need of:

Hot Prepared Meals

Counseling and Mental Health Services

Long-Term Assistance for repairing my home

Other (baby, adult care items, funding, etc.)

Please provide details (as appropriate) for the items/services requested.

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* 12. Please feel free to describe your situation and any needs that require more information. Please note that this information is not protected by HIPAA regulations and will be shared with the appropriate community organizations to best respond to the request.

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* 13. If you would like to report on a local organization (synagogue, etc.) that has sustained damage from the storm? If so, please provide the information below.

Organization Name

Organization Point of Contact (PoC)

PoC Phone Number

PoC Email Address

Description of Damage Sustained

Organizational needs at this time

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* 14. **I agree that the submission of this form is an acknowledgment that I understand the limitations of my privacy and that I voluntarily choose to participate and share my information and agree to waive my legal privacy rights, including those under HIPAA.

*Please note that selecting "No" inhibits our ability to deliver necessary services and goods.

Yes