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We want to hear from you!

ZIP Code *

How many are in your household? *

Is anyone in your household disabled? (Oxygen Dependent, Senior over 55+, Wheelchair)

Neighborhood *

What’s your preferred language?

Please check all that apply:

Are you CERT certified? (Community Emergency Response Team)

Are you a Community Leader?

Are you a community health worker?

Are you registered with the STEAR program? (State of Texas Emergency Assistance Registry)

COMMUNITY: Please share 3 community needs you saw during the most recent disaster?

COMMUNITY: Who did you see respond to the community?

COMMUNITY: What did you most NEED during the disaster?

DAMAGE: What type of damage did you see in your neighborhood?

ELECTRICITY: How long did it take for you to have your electricity restored?

UTILITIES: Which Utility Services were interrupted? (Lights, Water, Phone / Cable)

Are you or your organization affiliated with East Aldine?

Name

Phone

Please check all that apply.

Information

Volunteer

Block Leader

Are you interested in being CERT certified?

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