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* 1. Prefix - Please select one

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* 2. What is your first name?

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* 3. What is your last name?

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* 4. What is your address number?

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* 5. What is your street name?

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* 6. If applicable, what is your apartment/unit number?

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* 7. What is your telephone number?

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* 8. What is your email address?

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* 9. Which best describes the dwelling damaged in the April 18, 2013 flooding?

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* 10. Do you own or rent this dwelling?

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* 11. What is the depth of water, in inches, experienced in the basement of this dwelling as a result of the April 18, 2013 flooding?

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* 12. What is the depth of water, in inches, experienced in the first floor of this dwelling as a result of the April 18, 2013 flooding?

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* 13. Is the basement of this dwelling used as a living area?

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* 14. What type of insurance do you have?

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* 15. Is there obvious/visible structural damage to the dwelling?

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* 16. What type of installed flood control do you have in place at this location? Indicate all that apply.

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* 17. How much water collected in your street?

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* 18. Please provide any other general comments not addressed by this survey.

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