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North America West Area
Disaster Response Survey
Please use the following form to submit your disaster response. Sign-in is not currently required.
What is your full name?
*
*
Are you safe?
*
Are you safe?
No
Are you safe?
Yes
Are you, or is anyone in your family injured?
*
Are you, or is anyone in your family injured?
No
Are you, or is anyone in your family injured?
Yes
If Yes, how seriously?
Minor
Serious but not life threatening
Serious and life threatening
If seriously injured, please describe the injuries?
*
Has this disaster caused a death in your family?
*
Has this disaster caused a death in your family?
No
Has this disaster caused a death in your family?
Yes
Have you (and your family) evacuated your home or the area?
*
Yes
No
Partially
Enter the number of people in your family that have evacuated?
*
Where have you evacuated?
Other Family or Friends
Local Evacuation Center/Emergency Shelter
Other
Enter the name and or address of your evacuation location?
*
Is your home damaged or destroyed?
*
Is your home damaged or destroyed?
No
Is your home damaged or destroyed?
Yes
If Yes, what is the condition of your home?
Minimal Damage
Serious Damage but Livable
Destroyed or Unlivable
What is the name of your stake?
*
*
What is the name of your ward?
*
*
Would you like your church leaders to be able to contact you?
*
Would you like your church leaders to be able to contact you?
No
Would you like your church leaders to be able to contact you?
Yes
Phone Number
*
Additional Information
*
Data Privacy Agreement
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I acknowledge and agree to the collection of my personal and household information for the purposes of humanitarian emergency response efforts in my area. I understand that my information will be shared with local leaders. Privacy Notice: https://www.churchofjesuschrist.org/legal/privacy-notice?lang=eng&country=go
Data Privacy Agreement
No
Data Privacy Agreement
Yes
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