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{"sheet":"PRA and Privacy Statements","index":0,"n_rows":12,"n_cols":9,"rows_kept":12,"merged":[[0,0,0,8],[4,0,4,8],[5,0,5,8],[7,0,7,8],[9,0,9,8]]}
["Shelter Resident Assessment Tool - V 2.0"]
[{"$nulls":6},"OMB Control Number:",null,"1660-0142"]
[{"$nulls":6},"Expiration Date:",null,"XX/XX/XXXX"]
[]
["PAPERWORK BURDEN DISCLOSURE NOTICE: \nFEMA Form FF-104-FY-21-169 (formerly 009-0-42AV)"]
["Public reporting burden for this data collection is estimated to average 10 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472-3100, Paperwork Reduction Project (1660-0142) NOTE: Do not send your completed form to this address."]
[]
["PRIVACY ACT  STATEMENT \nAUTHORITY: FEMA collects, uses, maintains, retrieves, and disseminates the records within this system under the authority of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act), Pub. L. No. 93-288, as amended (42 U.S.C. §§ 5121-5207); 6 U.S.C. §§ 776-77, 795; the Debt Collection Improvement Act of 1996, 31 U.S.C. §§ 3325(d), 7701(c)(1); the Government Performance and Results Act, Pub. L. No. 103-62, as amended; Reorganization Plan No. 3 of 1978; Executive Order 13411, “Improving Assistance for Disaster Victims,” August 29, 2006; and Executive Order 12862 “Setting Customer Service Standards,” September 11, 2003, as described in this notice.\nPRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of determining eligibility and administrating financial assistance under a Presidentially-declared disaster. Additionally, information may be reviewed internally within FEMA for quality assurance purposes and used to assess FEMA's customer service to disaster assistance applicants. FEMA collects the social security number (SSN) to verify an applicant's identity and to prevent a duplication of benefits. \nROUTINE USE(S): FEMA may share the personal information of U.S. citizens and lawful permanent residents contained in their disaster assistance files outside of FEMA as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, including pursuant to routine uses published in DHS/FEMA-008 Disaster Recovery Assistance Files Notice of System of Records, 78 Fed. Reg. 25,282 (Apr.30, 2013) and upon written request, by agreement or as required by law. FEMA may share the personal information of non-citizens, as described in the following Privacy Impact Assessments: DHS/FEMA/PIA-012(a) Disaster Assistance Improvement Plan (DAIP) (Nov. 16, 2012); DHS/FEMA/PIA-027 National Emergency Management Information System - Individual Assistance (NEMIS-IA) Web-based and Client-based Modules (June 29, 2012); DHS/FEMA/PIA-015 Quality Assurance Recording System (Aug. 15, 2014). FEMA may share your personal information with federal, state, tribal, local agencies and voluntary organizations to enable individuals to receive additional disaster assistance, to prevent duplicating your benefits, or for FEMA to recover disaster funds received erroneously, spent inappropriately, or through fraud. CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: The disclosure of information, including the SSN, on this form is voluntary; however, failure to provide the information requested may delay or prevent the individual from receiving disaster assistance."]
[]
["Intent\nThe purpose of this form is to help FEMA understand how best it can support survivors as they transition out of temporary shelters. No information given will be used to determine eligibility for assistance. Eligibility for assistance will only be determined through the separate registration process. It is estimated that this form will take 10 minutes to complete. Do you wish to continue?\n\n\n"]
[]
["I accept the privacy statement: ",{"$nulls":4},"If Yes, please fill in the  Form"]

{"sheet":"Shelter Resident Data Form","index":1,"n_rows":23,"n_cols":2,"rows_kept":23,"merged":[[0,0,0,8],[15,5,15,6],[22,5,22,6]]}
["Shelter Resident Assessment Tool - V 2.0\nFEMA Form FF-104-FY-21-169 (formerly 009-0-42AV)"]
[]
["Shelter Resident Information for the Head of Household:"]
[]
[null,"FEMA Disaster Assistance Registration ID (if available)"]
[null,"Shelter Name"]
[]
[null,"First Name"]
[null,"Last Name"]
[]
[null,"Mobile Phone Number"]
[]
[null,"Damaged Dwelling Street Address"]
[null,"Damaged Dwelling City"]
[null,"Damaged Dwelling State"]
[null,"Damaged Dwelling County"]
[null,"Damaged Dwelling Zip"]
[]
[null,"Number of Individuals in Household"]
[null,"Number of Individuals under 18"]
[null,"Number of Individuals over 60"]
[]
[null,"Household members need for communication support and durable medical equipment"]

{"sheet":"FEMA Data Spreadsheet","index":2,"n_rows":26,"n_cols":17,"rows_kept":26}
[null,"No.","FEMA Registration ID","Shelter Name","Head of Household: First Name","Head of Household: Last Name","Head of Household: Phone Number (Enter With No Spacing)","Damaged Dwelling (DD): Street Address","Damaged Dwelling (DD): City","DD: State","DD: County","DD: Zip Code","Number of Individuals in Household","Number of Individuals in Householdunder 18","Number of Individuals in Householdover 60","Household members need for communication support and durable medical equipment","Notes"]
[null,1]
[null,2]
[null,3]
[null,4]
[null,5]
[null,6]
[null,7]
[null,8]
[null,9]
[null,10]
[null,11]
[null,12]
[null,13]
[null,14]
[null,15]
[null,16]
[null,17]
[null,18]
[null,19]
[null,20]
[null,21]
[null,22]
[null,23]
[null,24]
[null,25]

{"sheet":"SRAT V 2.0 Full Survey","index":3,"n_rows":98,"n_cols":6,"rows_kept":98,"merged":[[0,0,1,4],[0,5,14,12],[2,3,7,4],[5,0,97,0],[8,3,8,4],[9,3,9,4],[10,3,10,4],[11,3,11,4],[12,3,12,4],[13,3,13,4],[14,3,14,4],[15,3,15,4],[16,3,16,4],[17,3,17,4],[18,3,18,4],[19,3,19,4],[20,3,20,4],[21,3,21,4],[22,3,22,4]]}
["Shelter Resident Assessment Tool - V 2.0\nFEMA Form FF-104-FY-21-169 (formerly 009-0-42AV)",{"$nulls":4},"Privacy Statement, read in its entirety: \"We are required to provide you with the following Privacy Act Statement. The Privacy Act of 1974 protects your rights as to how FEMA uses and shares your information.                             The Stafford Act and other authorities allow FEMA to collect this information to determine eligibility and administer financial assistance as a result of an Emergency or Presidentially declared disaster.                                         FEMA may share your information outside of FEMA with entities such as States, Tribes, local government, voluntary organizations and other organizations in accordance with published routine uses. FEMA shares this information to enable you to receive additional disaster as stance and as necessary to prevent duplication of benefits and prevent future disaster losses.                     FEMA may record phone calls for internal quality assurance purposes. Furnishing your SSN and other requested information in voluntary, however, failure to provide may delay or prevent you from receiving as stance.                     If you knowingly make false statement to obtain disaster aide, it is a violation of federal and State laws. "]
[]
["Step 1:","DR#"]
["Step 2:","Shelter Name: ","Enter official name of the shelter, do not abbreviate shelter name. "]
["Step 3:","Assessment "]
[null,"1. Do you understand and agree with the Privacy Statement:"]
[null,"a. yes"]
[null,"b. no","If no, go to end of survey and provide FEMA # and/or DRC"]
[null,"2. Do you or any household member need any communication tools to support your recovery? ","Let shelter resident communicate freely, and check box in a drop down list","Drop Down Menu"]
[null,"3. Do you or any member of the household need specialized medical equipment (i.e.. Mobility, sensory and/or access ability needs)?",null,"Language "]
[null,"a. Yes (free text)",null,"ASL, Deaf/Blind, Oral Interpreter"]
[null,"b. no (next question)",null,"Hearing"]
[null,"4. Do you have a FEMA registration number?",null,"Hearing Aids"]
[null,"a. No (go to question 6)",null,"Relay Services"]
[null,"b. Yes (next question)",null,"Cap Tel Phones "]
[null,"c. Unknown or unknown FEMA number (go to question 7)","At the end of the survey look up FEMA number. If they did not register, ask if they would like to register. ","Cart"]
[null,"5. What is your FEMA registration number? (free text)",null,"Hearing Aid Batteries"]
[null,"Free Text (go to question 14)",null,"Tactile Graphics"]
[null,"6. Would you like to register for FEMA assistance? ",null,"Vision"]
[null,"a. Yes","refer to registration intake after survey","Screen Readers"]
[null,"b. No",null,"Screen Magnification "]
[null,"7. First Name (free text)",null,"Scanning Systems"]
[null,"8. Last Name including suffix (free text)",null,"Braille"]
[null,"9. Prior to the disaster were you:"]
[null,"a. Owner"]
[null,"b. Renter"]
[null,"c. Homeless","Go to question, 11. Additionally, a Series of questions that will need to be skipped if homeless is checked. Note: Define homelessness in training. "]
[null,"10. Pre-disaster Address"]
[null,"Street:"]
[null,"City:","Discussion when built out into the system"]
[null,"State/Territory:"]
[null,"County:"]
[null,"Zip Code:"]
[null,"11. Mobile Phone Number:","(Include relay service, if needed)"]
[null,"Free Text"]
[null,"12. Email Address:"]
[null,"Free Text"]
[null,"13. Including yourself, how many household members are currently in the shelter?                                     A. How many adults are over the age of 60?                                                               B. How many children are under 18? "]
[null,"Free Text"]
[null,"14. Are you or anyone in your household active-duty military or a U.S. Veteran?"]
[null,"a. Yes"]
[null,"b. No"]
[null,"15. Do you have pets?"]
[null,"a. No (go to question 17)"]
[null,"b. Yes "]
[null,"16. What type of pets do you have?"]
[null,"Free Text"]
[null,"17. Do you live in Hud-assistance housing (Section 8 or subsidized Housing)? ","Skip if homeless"]
[null,"a. Yes"]
[null,"b. No"]
[null,"c. unknown"]
[null,"18. Is your home inaccessible? ","Skip if homeless Note: Provide examples in training. "]
[null,"a. No (next question)"]
[null,"b. Yes (Go to 24)"]
[null,"c. unknown (Go to 24)"]
[null,"19. Is your water currently operable at your pre-disaster home? ","Skip if homeless"]
[null,"a. yes (go to question 21)"]
[null,"b. no (next question)"]
[null,"c. unknown (go to question 21)"]
[null,"20. What is the issues and expected fix date? "]
[null,"Free Text"]
[null,"21. Are all utilities available at your pre-disaster home?","Skip if homeless"]
[null,"a. Yes (go to question 23)"]
[null,"b. no (next question)"]
[null,"c. unknown (go to question 23)"]
[null,"22. What is the issue and expected fix date?"]
[null,"Free Text"]
[null,"23. Do you need assistance with moving debris or mud out of your pre-disaster home?","Skip if homeless Note: Provide examples in training. "]
[null,"a. yes","If able, have them sign an ROI. "]
[null,"b. no"]
[null,"c. unknown"]
[null,"24. Do you have a plan to move out of the shelter?"]
[null,"a. Return to pre-disaster home"]
[null,"b. Stay with family and/or friends"]
[null,"c. Identify an available rental"]
[null,"d. Purchase a new home"]
[null,"e. Move into a secondary home"]
[null,"f. I do not know"]
[null,"25. Are you having difficulty with planning your shelter transition?"]
[null,"a. Yes (Next question)"]
[null,"b. No (go to question 28)"]
[null,"26. What are the challenges?"]
[null,"a. No housing or hotel with reasonable commuting distance "]
[null,"b. No short-term lease available"]
[null,"c. No housing accepting pets"]
[null,"d. No affordable housing"]
[null,"e. If it does not meet one of the above, please note reason at the end of the assessment"]
[null,"27. Are you willing to temporally move outside the local area of your pre-disaster home while conditions stabilize or repairs are being made?","Skip if homeless"]
[null,"a. Yes"]
[null,"b. No"]
[null,"28. Do you have a scheduled move out date from your current shelter?"]
[null,"a. Yes (Date)"]
[null,"b. No"]
[null,"29. Do you have transportation issues that prevent you from meeting with an inspector?","Skip if homeless"]
[null,"a. No"]
[null,"b. Yes (please explain)"]
[null,"30. Any additional information you would like to provide. "," (no Personal Identifiable Information (PII) )"]
[null,"Free Text"]

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