Disaster Relief Form
Name
Gender
Male
Female
Other
Age
Location
Latitude
Longitude
No. of People in Household
Displaced
Yes
No
No. of Deaths
No. of Injured
Building Status
Partially Damaged
Destroyed
Intact
Building Type
Residential
Commercial
Industrial
Public
Access to Shelter
Yes
No
Access to Clean Water
Yes
No
Access to Food
Yes
No
Medical Assistance
Needed
Not Needed
Evacuation Date
Assistance Received
Yes
No
Remarks
Submit
