Rapid Needs Assessment

Date of Visit (mm/dd/yy) Disaster Coordinator:

Church Surveyor's Name

Brief Description of the Incident (Type of Disaster, When and where it occurred)

LOCATION
Community Name: Where is your church operating from? Is the church serving as a distribution point? Zip Codes Affected: Deanery:

Yes

No

POPULATION AFFECTED
Estimated Population Estimated Evacuated All females All males Under 5 Over 60

Current
Unaccompanied Elders Unaccompanied Minors Severe Disabilities Chronically Ill Female Headed Households

Vulnerable Persons

COMMUNIY RESOURCES
Population with Shelter 100% 75% 50% 25% 0% > 3m Available Food 2m 1m 1wk None 24hr Electricity Some None Enough Water Some None

DAMAGE TO THE COMMUNITY

Total homes (number) Little or no damage Inhabitable if repaired Destroyed Tools / Materials needed for local repair

Damage to homes Summarize Damage sustained to Catholic Charitites Properties

Services at your facility (Y/N)

Electricity

Phone

Cell Phone

Sewage

Gas

Water

Internet

Rapid Needs Assessment

SERVICES REQUESTED
MEDICATION / OTHER MEDICAL NEEDS (Durable Medical Equipment, etc.) PERSONAL PROPERTY REPLACEMENT (Autos, appliances, furniture) FINANCIAL ASSISTANCE (Rent, utilities, etc.) High Medium Low

Main Needs (Circle)

High Medium Low

High Medium Low

High Medium Low

High Medium Low

High Medium Low

High Medium Low

HOME REPAIR

COUNSELING

CLOTHING

SHELTER

FOOD

High Medium Low

How has the agency responded to requests for service?

CURRENT ASSISTANCE
Organization Name: Water Construction Shelter MREs Health

What action has been taken by the affected community?

ADDITIONAL REMARKS

Insert Agency Contact Information

Source: Catholic Charities Archdiocese of New Orleans