Hurricane Zeta Tribal Citizen Impacts Reporting Form Hurricane Zeta Tribal Citizen Impacts Reporting Form UHN Tribal Citizens can use this form to fast track notice to the UHN Disaster Response Team to aid in preparing a timely assessment of community needs and distribution of resources when received. Citizen Name* First Middle Last Suffix Citizen Maiden Name (if applicable)Tribal Roll NumberAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Email How many people reside in your household?*Does anyone over the age of 55 reside in your home?* Yes No Did you evacuate because of this event?*No. Sheltered in place.Yes. Stayed with family living further inland away from the storm.Yes. Rented a hotel, motel or other commercial location at a daily cost.Yes. Stayed at a shelter opened for evacuees.What type of damage was inflicted on your home structure from this storm?Roof damage (leaks, missing materials, etc.)Structural Shifts (moved from blocks)Flooding and moisture to the sub floor onlyFlooding in the home up to 1 footFlooding above 1 footDowned trees or flying debris damageCheck the primary damage to your home. You can add other items below.What personal losses did you incur due to this storm?Extra expenses to run generator during power outages.Loss of perishable food in refrigerator and/or freezers due to power outages.Unable to work due to storm decreasing my income.Please indicate your greatest loss. Choose one. You can address other items in the space below.What is the ownership status of your home?* Own/Mortgage Rent Family Home Staying with Friends Do you have homeowners insurance?* Yes No Basic coverage for wind damage at a minimum.Is your home covered by flood insurance?* Yes No Please share any other conditions not included in this survey that the UHN needs to be aware of when speaking with funders and media regarding your needs.A picture is worth a thousand words. If you are willing to share photos of damage in your community so that the UHN can advocate for your needs, please upload here. By uploading you are granting permission to the UHN to utilize the photos to document impacts of Hurricane Barry. Drop files here or You may upload up to 5 images.
