Disaster Response Survey

OMB Control Number: 2502-0615

DISASTER RESPONSE SURVEY to assess the immediate impact of a disaster on an
agency’s operations and capacity to provide services.
OMB Control Number: 2502-0615
Expiration Date:
Public reporting burden for this collection of information is estimated to average 1 hour per response,
including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed and completing and reviewing the collection of information. The
information collected will be used assess the operational status of housing counseling agencies after a
disaster to determine needed assistance. This collection of information is voluntary. The agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless that
collection displays a valid OMB control number. Responses are protected from disclosure pursuant to the
Privacy Act of 1974. HUD will prosecute false claims and statements. Conviction may result in criminal and/or
civil penalties. (18 U.S.C. 1001, 1010, 1012;31 U.S.C. 3729, 3802).

The Office of Housing Counseling (OHC) is monitoring the impact on your community and agency,
due to a recent disaster. You and your agency may have been impacted by this disaster and our goal
is to help support you. We know you and your agency are an important part of your community and
its response and recovery. To help support you, your clients, and your community we are sending
this initial response survey to assess the impact of the disaster on your agency’s operations and
capacity to provide services.
Your response to this survey is voluntary.
Required questions are marked with an asterisk. All other questions are optional. Please provide
information based on the current situation of your agency as it relates to the most recent disaster.
Your survey responses will help OHC understand your current operating status and evaluate the
needs of your agency and your clients.
Thank you for completing the initial OHC Disaster Response Survey. If you would like assistance,
please contact your OHC POC or send an email to OHCDart@hud.gov

Agency Information
1. * Name of Housing Counseling Agency (Agency)
2. * Agency HCS ID Number
3. Identify the federally declared disaster that has impacted the area your agency serves.
a. Date and Name of Declaration
4. Identify the local, state, regional disaster that has impacted the area your agency serves.
a. Date and Name of Declaration
5. Disaster Type (i.e. flood, fire, etc.)
i. Narrative
6. Who is the current contact for your agency? Please share their contact information.
a. Name
b. Title
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OMB Control Number: 2502-0615

c.
d.
e.
f.
g.

City/Town
State
Zip Code
Email Address
Phone Number

Agency Operations
2. *Select from the options below how the most recent disaster has impacted your agency
operations to provide housing counseling. Select all that apply.
a. Currently not providing services
b. Inoperable or damaged communications systems (phone or postal service)
c. Inoperable or damaged telecommunication systems (internet, computer, or
cellular)
d. Building was damaged or limitations with physical workspace for staff and/or public.
e. Building is closed to staff.
f. Agency staff are teleworking.
g. Agency staff are providing services offsite where disaster impacted clients are
located.
h. Building is closed to the public.
i. Staff were impacted and have limited ability to provide services.
j. Community infrastructure has been impacted (roads closed, limited community
services, etc.).
k. Other:
i. Please enter comment, if other has been selected.
l. Not Applicable
3. Share the post-disaster needs of your agency, impacting its services. Select all that apply.
a. Training
b. Technical Assistance
c. Other
i. Please enter comment, if other has been selected.
d. None of the above
Other Disaster Information
4. Does your agency have a Continuity of Operations Plan (COOP)? If so, please share any
actions or protocols activated in response to the disaster?
a. We do have a COOP and it was activated.
b. We do have a COOP but it was not activated.
c. We do not have a COOP.
i. Narrative of actions triggered:
5. Does your agency have an Emergency Response Plan? If so, please share any actions or
protocols activated in response to the disaster?
a. We do have an Emergency Response Plan and it was activated.
b. We do have an Emergency Response Plan and it was not activated.
c. We do not have an Emergency Response Plan.
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OMB Control Number: 2502-0615

i. Narrative of actions triggered:
6. Please share any other comments or observations.
Narrative

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