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1. Does your agency provide direct service?

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2. What type of service(s) do you provide?

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3. Has you ability to serve your constituencies been impacted by Superstorm Sandy?

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4. Are some or all of your facilities temporarily closed due to the storm?

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5. How has your ability to serve been impacted? Check all that apply.

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6. If you do not have power, are you relying on a generator to keep services going?

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7. Approximately how many clients do you think you were unable to serve that would normally receive services?

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8. Do you expect an increase in the number of people seeking help?

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9. Do you expect increased demand for services across the board?

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10. Do you anticipate long term delays (more than 1 week) for full restoration of services?

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11. Have you shifted or do you anticipate shifting the focus of your work for some period of time to respond to
new client needs or new clients as a result of Sandy?

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12. Do you serve populations that have been evacuated?

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13. Have all of the families who were evacuated been accounted for?

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14. Are your services funded in full or in part through a government contract? (check all that apply)

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15. Name of your Organization (optional):

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16. Additional comments:

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