Initial Damage Assessment Report
Please complete this with as much information as possible; this will assist when determining if aid will be an option for this incident.
Who is completing this form?
*
Public Safety Agency / Government / Non-Governmental Organization
Resident
How are you taking this form?
Online (Self/Assisted)
Call Center
Location of Damages
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Types of Damages
Please Select
Debris
Private Property Damage
Public Property Damage
Flooded Road
Emergency Protective Measures
Is this critical infrastructure?
Yes
No
Is this a military asset?
Yes
No
Business Name (if applicable)
Resident Name
First Name
Last Name
Resident Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Incident Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does resident have insurance?
*
Yes
No
Not Sure / Needs Follow-up
Type of Property
*
Single Family
Multi Family
Business
Vacation Home
Other
Ownership
*
Rent
Own
Lease
Not Sure / Needs Follow-up
Source of Damages
*
Fire
Flood
Wind Event / Tornado
Earthquake
Winter Storm
Other
Please specify source of damages if you choose other option
Detailed Description of the Damage/Problem
Upload a photo(s) of the damage
Browse Files
Drag and drop files here
Choose a file
Cancel
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Are you a veteran?
Yes
No
Were you a business that was evacuated or impacted by this disaster?
Yes
No
Are you employed and evacuated due to this disaster and need assistance?
Yes
No
I am feeling overwhelmed.
Yes
No
Service Needs (Check all that apply)
Clothing (adult)
Building Repair
Damage Inspection / Proof of Damage
Impacted Business Needs
Shelter Questions
Disaster Questions - Law Enforcement
Clothing (child)
Clean up Assistance
Food
Identification Documents Destroyed
Utility Questions
Rental Questions
Other
Questions or Comments?
Person Completing Form (if other than self)
First Name
Last Name
Submit
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