AFTNJ Disaster Response Survey

Hurricane Sandy: Need Help or Want to Help Out?

AFT New Jersey needs to hear from you if you:

Suffered loss from Hurricane Sandy and need assistance; or
Can volunteer to assist your union colleagues and their communities recover from the storm.

Please take a moment and let us know what you need or how you can help.

Please visit AFTNJ's webpage at http://aftnj.org/ for more information on disaster relief and assistance.

Thank you for your time.

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1. Name:

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2. Work Location:

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3. Phone number where you can be reached:

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4. Best email to contact you:

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5. Home Address:

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6. I suffered damages and loss from the storm.

Yes

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7. Have you been displaced from the address listed above?

Yes

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8. Please give us details about the impact of the storm on you and your family:

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9. If yes, have you contacted or filed with FEMA?

Yes

Not Yet

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10. If no, do you need any help with FEMA paperwork?

Yes

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11. Please tell us what forms of assistance would be helpful to you (check all that apply):

	Yes	No	Maybe
Help with work-related issues (leave of absence, transportation needs, etc.)	Help with work-related issues (leave of absence, transportation needs, etc.) Yes	Help with work-related issues (leave of absence, transportation needs, etc.) No	Help with work-related issues (leave of absence, transportation needs, etc.) Maybe
Help with housing/shelter	Help with housing/shelter Yes	Help with housing/shelter No	Help with housing/shelter Maybe
Monetary assistance	Monetary assistance Yes	Monetary assistance No	Monetary assistance Maybe
Counseling	Counseling Yes	Counseling No	Counseling Maybe
Supplies	Supplies Yes	Supplies No	Supplies Maybe
Help cleaning up flood-damaged home	Help cleaning up flood-damaged home Yes	Help cleaning up flood-damaged home No	Help cleaning up flood-damaged home Maybe

Other (please specify)

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12. If you need supplies, please let us know what you need (cleaning supplies, toiletries, batteries, etc.)

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13. I would like to volunteer.

Yes

Maybe

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14. Do you have any training in emergency response (CERT, OSHA, FEMA)?

Yes

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15. If Yes, would you be willing to help with emergency response coordination efforts?

Yes

Maybe

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16. Other ways to help (check all that apply):

	Yes	No	Maybe
Willing to help with distribution of donations/supplies	Willing to help with distribution of donations/supplies Yes	Willing to help with distribution of donations/supplies No	Willing to help with distribution of donations/supplies Maybe
Willing to work in cleanup efforts	Willing to work in cleanup efforts Yes	Willing to work in cleanup efforts No	Willing to work in cleanup efforts Maybe
Willing to donate supplies, such as water, canned goods, diapers, blankets, flashlights, shovels, pet food, furniture, generators, etc.	Willing to donate supplies, such as water, canned goods, diapers, blankets, flashlights, shovels, pet food, furniture, generators, etc. Yes	Willing to donate supplies, such as water, canned goods, diapers, blankets, flashlights, shovels, pet food, furniture, generators, etc. No	Willing to donate supplies, such as water, canned goods, diapers, blankets, flashlights, shovels, pet food, furniture, generators, etc. Maybe
Have access to short-term housing options for members and/or pets	Have access to short-term housing options for members and/or pets Yes	Have access to short-term housing options for members and/or pets No	Have access to short-term housing options for members and/or pets Maybe
Willing to help with fundraising efforts for disaster relief	Willing to help with fundraising efforts for disaster relief Yes	Willing to help with fundraising efforts for disaster relief No	Willing to help with fundraising efforts for disaster relief Maybe

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17. Which local are you a member of?

	Local
Select your local:	Select your local: Local menu

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* 1. Name:

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* 2. Work Location:

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* 3. Phone number where you can be reached:

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* 4. Best email to contact you:

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* 5. Home Address:

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* 6. I suffered damages and loss from the storm.

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* 7. Have you been displaced from the address listed above?

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* 8. Please give us details about the impact of the storm on you and your family:

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* 9. If yes, have you contacted or filed with FEMA?

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* 10. If no, do you need any help with FEMA paperwork?

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* 11. Please tell us what forms of assistance would be helpful to you (check all that apply):

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* 12. If you need supplies, please let us know what you need (cleaning supplies, toiletries, batteries, etc.)

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* 13. I would like to volunteer.

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* 14. Do you have any training in emergency response (CERT, OSHA, FEMA)?

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* 15. If Yes, would you be willing to help with emergency response coordination efforts?

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* 16. Other ways to help (check all that apply):

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* 17. Which local are you a member of?

1. Name:

2. Work Location:

3. Phone number where you can be reached:

4. Best email to contact you:

5. Home Address:

6. I suffered damages and loss from the storm.

7. Have you been displaced from the address listed above?

8. Please give us details about the impact of the storm on you and your family:

9. If yes, have you contacted or filed with FEMA?

10. If no, do you need any help with FEMA paperwork?

11. Please tell us what forms of assistance would be helpful to you (check all that apply):

12. If you need supplies, please let us know what you need (cleaning supplies, toiletries, batteries, etc.)

13. I would like to volunteer.

14. Do you have any training in emergency response (CERT, OSHA, FEMA)?

15. If Yes, would you be willing to help with emergency response coordination efforts?

16. Other ways to help (check all that apply):

17. Which local are you a member of?