PUBLIC ASSISTANCE - PRELIMINARY DAMAGE ASSESSMENT

FAX or E-Mail to ___________ Co. at ___________________________

Name of Jurisdiction: Reporting Official:
__________________________________________________________________________________

Address: Title:

__________________________________________________________________________________

Telephone:

___________________________

Type of Disaster: Date of Incident:

__________________________________________________________________________________

Population: Yearly Budget:

Criteria: Restore to Pre-Disaster Condition

Include a brief description of Health & Safety Issues involving Categories A through G: Example: Road or bridge out and fire or rescue can’t get to home.

Cat. A: Debris Removal: OT hours, all Equipment hours,

all Materials and reasonable Contracts: Cost:__ __________

Cat. B: Emergency Protective Measures: OT hours,

all Equipment hours, all Materials and reasonable Contracts: Cost:______________

Cat. C. Roads &Bridges:

List Bridge/Rd # and type of damage: Cost:______________

Cat. D. Water Control Facilities:

List & describe type of damage: Cost:______________

Cat. E. Buildings & Equipment:

List & describe type of damage: Cost:______________

Cat. F. Public Owned Utilities:

List & describe type of damage: Cost:_______________

Cat. G. Parks, Recreational Facilities:

List & describe type of damage: Cost:_______________

Total Costs: _______________

Submitting Official:

Signature:__________________________________________Date:______________________

Title:_____________________________________________ Telephone:__________________