SCREENING CHECKLIST

SCREENING CHECKLIST (cont.)

Are insurance, federal, state, local and/or family resources sufficient to meet disaster-caused needs?
( )yes ( )no

Explain:
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What is family's stated need?
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Has family obtained estimates for repairs or replacement of the residence? ( )yes ( ) no

Amount of estimates _____________

Obtained permits/inspections? ( )yes ( )no

Checked elevation requirements? ( )yes ( )no

Further agency involvement needed? ( ) yes ( )no

Name of person completing form_____________________________________________

Date:_______________

*Comments
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*Include number of family members and ages, when available