One Door — Recovery Outreach & Data System

Form language:

Filling out for:

Myself Someone else

Your info is shared to help meet needs directly and coordinate advocacy — not shared with any government agency. Full details below.

About Your Household

Household size (optional)

Anyone in your household (check all that apply)

Keiki (children) in household Kupuna (elders) in household Disabled Chronic mental or physical health conditions Pregnant or postpartum

What happened?

What type of damage or impact did you experience?

Flooding (home / yard) Mud / debris / downed trees Structural damage (roof, walls, foundation) Loss of personal belongings Struggling to pay rent or mortgage Lost wages or unpaid time off Other

Estimated property damages ($)

Not including farm/ag losses

Are you a farmer or producer?

Yes No

Farm / operation name

Farm community

What do you grow / raise?

Add an agricultural need

Select a category, check items and add notes, then select the next category to save. Repeat for each need.

Mahalo!