INITIAL IMPACT ASSESSMENT FORM           Vers 1.4

Location:

Precedence:  

1A) Is EOC Activated? 1B) EOC Activation status?
   

   


1C) State of Local Emergency Declared?

1D) EOC Comments: (i.e. Number of staff /status of EOC, etc.)
 

1E) First Responders Status: (Include details pertaining to personnel and Apparatus)
 
2) Priority Needs (3 only)
    1)
    2)
    3)
People Impacted (Estimated/Confirmed):
3A

# Displaced

 3B

# Injured

 3C

# Fatalities

 3D Evacuations? 3E

# Evacuated

Critical Infrastructure

Provide impact description and Estimated Time to Repair (ETR)

  Impacted? Comments ETR
4A Water
4B Sanitation
4C Gas
4D Electricity
4E Telephone
4F Internet
4G Cellular Network
4H Text Messaging
4I SAT Phone

Amateur Radio Station

4J) Status: ETR:
  Callsign:
  Winlink address:

5A) If potable water system is unusable, estimated days remaining of water:

5B) Estimated days remaining of food:

6) Primary Transportation Route - available into community and at least one alternate route:  
 

7) Medical - Hospitals/Clinics:  
 

8A) Shelter - estimated % of homes uninhabitable:

8B) Estimated percentage of Rapid Damage Assessment completed:


9) Comments:
 
Report Originator:

Organization:
Functions
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