Business Name*
Business Address*
Business phone*
x
Contact name*
Main Contact Email address*
Main Contact Mobile number*
Date of Survey Completion*
Community location*
Business sector
Business Details
Industry type (Select One)
If Other, please specify
Disaster Impact
What type of disaster affected your business? (Select all that apply)
If Other, please specify
Was, or is, your business forced to close or modify operations as a result of the disaster?
Is your business currently open?
If applicable, estimated reopening date
What challenges are you currently facing? (Select all that apply)
If Other, please specify
Employment and Revenue
How many employees did you have before the disaster?
How many employees do you currently have?
Do you expect to rehire or hire new staff in the next 3–6 months?
Estimate the change in your sales or revenue since the disaster
Do you expect sales to return to pre-disaster levels?
If Yes, estimated recovery timeframe
Support and Resources
Have you accessed any disaster relief programs (federal, provincial, municipal, Red Cross or non-profit)?
If Yes, which ones?
What additional support would help your recovery?
Would you like someone from our core of volunteers, your local government, or the economic development office to follow up with you?
If Yes, please provide your contact details again. (Name, Phone, Email)
Please verify that you are a real person*