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INITIAL DAMAGE ASSESSMENT FORM

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INITIAL DAMAGE ASSESSMENT FORM

    TAB C REPORTING DAMAGES (FORMS)

    12 HOUR EVENT OVERVIEW FORM

1. WHAT HAPPENED: (Flood, explosion, tornado, fire, etc.)

    2. WHEN DID IT HAPPEN:

    3. WHERE DID IT HAPPEN:

    4. EXTENT OF DAMAGE OR LOSS:

    5. BEST ESTIMATE OF INJURED, HOMELESS, FATALITIES:

    6. TYPE AND EXTENT OF ASSISTANCE REQUIRED, IF KNOWN:

    7. ADDITIONAL REMARKS PERTINENT TO SITUATION:

    DRB 07/2005

    TAB C REPORTING DAMAGES (FORMS)

    OHIO EMERGENCY MANAGEMENT AGENCY

    DAMAGE AND NEEDS ASSESSMENT FORM

    INSTRUCTIONS

    The following instructions will assist you in providing the information on the Damage and Needs Assessment Form, AGN-035, Revised April, 1990. The completion of this form as soon as

    practical after the disaster has occurred allows for an expeditious decision by higher authorities to determine possible future action by the State and/or Federal government.

    It is suggested that where figures are not immediately available, a reasonable estimate of costs be inserted. The information provided on this form gives State officials a broad picture of the impact of the disaster on your community and enables them to identify those programs which may be suit your community’s needs.

    This data should be reported to the Ohio Emergency Management Agency (Ohio EMA) as soon as possible if your community is seeking assistance from the State or Federal government. If you know that the Ohio EMA Assessment Room is being staffed, please report the data verbally by calling 614-799-3911, or fax the data to 614-764-2742. Otherwise, you may report the data

    verbally by calling 614-799-3665, or fax the data to 614-799-0018. The form itself is a

    worksheet which can be mailed to Ohio EMA at a later data as “hard copy” of previous verbal transactions.

    You MUST prepare maps showing the locations of the damaged areas referenced on the assessment form for later on-site verification. A copy of the map(s) can be mailed in with the form to Ohio EMA. However, one should be retained at your location in the event site inspection should occur prior to our receipt of your map in the mail.

    One form should be completed for each affected political jurisdiction, to include a separate form for the County as a separate jurisdiction.

    GENERAL SECTION

    Enter the name and population of the political jurisdiction for which damage BLOCK A:

    estimates are being recorded.

    Enter the name and population of the county. BLOCK B:

    Indicate the type of disaster and the date of occurrence. If it is a flood or winter BLOCK C:

    storm disaster, provide additional information as requested in BLOCK N.

    Indicate the area where the damage has occurred. BLOCK D:

    Provide the name, title, address, and phone number of the person to be contacted BLOCK E:

    should questions arise concerning the data provided.

Updated: 2/25/04 Page 1 of 4

    TAB C REPORTING DAMAGES (FORMS)

    PUBLIC DAMAGE SECTION

Public damages are those damages to government-owned properties and facilities, and for the

    purposes of damage assessment, are based on what cost is involved to return those properties to their pre-disaster condition. As indicated below, the term “public damage” also includes those out-of-pocket costs the government incurred in their response to the disaster.

    In the event a joint Federal/State preliminary assessment is conducted to determine the need for Federal assistance, additional information concerning public damages is required. You should refer to the Damage Assessment Guide, August, 1995, developed and distributed by the Ohio EMA for additional guidance.

    DEBRIS CLEARANCE The debris must be a direct result of the disaster. BLOCK A:

    Enter costs incurred/projected for debris removal from public property. Do not

    include debris removal estimates from private property, unless government

    forces would normally have a legal responsibility to do so. Include actual and

    estimated costs to remove debris from public roads and streets within your

    jurisdiction, even those which may be on the Federal Aid system.

    PROTECTIVE MEASURES Protective measures can include the cost of BLOCK B:

    search and rescue, demolition of unsafe structures, and actions taken by

    governmental forces to reduce the threat to public health and safety as a direct

    result of the disaster. Costs for sandbagging and other flood protective actions,

    barricades and signs, extra police and fire including overtime pay, emergency

    stream clearance, health measures, and temporary measures are eligible under

    this category.

    ROAD SYSTEMS Enter the actual/estimated cost to return the following BLOCK C:

    public property, which may have been damaged or destroyed by this disaster, to

    its pre-disaster condition: the type and number of miles of roads receiving

    damage; the number of bridges and culverts destroyed or damaged; damage to

    the rights-of-way, curbs, sidewalks, street lights, and gutters. Indicate whether

    access problems still exist.

    WATER CONTROL FACILITIES Flood control, drainage, and irrigation BLOCK D:

    facilities which are owned, operated, controlled, or maintained by a local unit of

    government, and which received damage due to the disaster are recorded in this

    block.

    PUBLIC BUILDINGS, FACILITIES, AND EQUIPMENT Enter the BLOCK E:

    number destroyed or damaged and the estimated cost of repair of any

    government-owned facility damaged by this disaster. This could also include any

    government-owned equipment directly damaged by the disaster (not those

    damaged during the response), replacement of broken windows, and damaged

    roofs. Complete all categories where damage costs are incurred or projected.

    Include an estimate of the insurance coverage if possible.

    Updated: 2/25/04 Page 2 of 4

    TAB C REPORTING DAMAGES (FORMS)

PUBLIC UTILITIES Enter all costs as appropriate for damages to publicly BLOCK F:

    owned utilities and utility systems. These costs can be both emergency repairs

    and/or projected costs of permanent replacement, if necessary. Include the estimated insurance coverage.

PARKS AND RECREATIONAL Enter all costs as appropriate for damages BLOCK G:

    to parks and recreational facilities.

SCHOOLS AND PRIVATE NON-PROFIT FACILITIES Enter the BLOCK H:

    number of damaged or destroyed schools (public and private) and an estimated or actual cost for repairs and or the projected costs of permanent replacement. Other non-profit facilities may be included, such as: museums, community

    shelters (i.e. Senior Citizen or homeless), libraries, emergency and medical facilities, private utility and other facilities which provide essential governmental services.

COMMUNITY BUDGET INFORMATION It is mandatory that political BLOCK I:

    jurisdictions affected by the disaster complete this section if they are seeking Federal disaster relief through the Estate. If a joint Federal/State site assessment is arranged, representatives from the Federal Emergency Management Agency

    (FEMA) require the jurisdictions to provide hardcopies of this information.

    PRIVATE DAMAGE SECTION

INDIVIDUAL List the number of structures (primary residences including BLOCK J:

    mobile homes and farm houses) which were destroyed or received major or

    minor damage from the disaster. Do not report secondary residences (i.e. vacation homes) in this block. Report them separately under comments.

    Destroyed: Totally uninhabitable, beyond repair. If a local ordinance prohibits the issuance of a permit for repairs to a structure damaged beyond a certain degree, that structure should be included in this section.

    Major Damage: The structural damage is such that the occupant cannot repair the structure within thirty (30) days; uninhabitable without major structural repairs. NOTE: Water above the floor of a mobile home for any significant length of time generally causes major damage, even though some occupants may choose to move back in.

    Minor Damage: The structural damage can be repaired within a thirty (30) day time period.

    These definitions are provided to assist you I assessing damage to private structures and are generally utilized by FEMA during joint Federal/State assessments. Some

    Updated: 2/25/04 Page 3 of 4

    TAB C REPORTING DAMAGES (FORMS)

    organizations, such as the Red Cross, do not categorize major/minor damage in

    the same way and utilize their own criteria when performing a damage assessment.

    BUSINESS/INDUSTRY Furnish the number of businesses and industries BLOCK K:

    destroyed or with major and minor damage as defined under Block J. You need

    to supply the percentage of insurance coverage and any significant information

    concerning the impact of the damage, such as the number of persons

    unemployed because of the damages and an estimate of the duration of that

    unemployment

    AGRICULTURAL The information provided here concerns losses to BLOCK L:

    operating farms. In this block, document the number of service buildings,

    machinery and equipment, crops, and livestock which were destroyed or

    received major or minor damage. This information is shared with the Ohio

    Department of Agriculture.

    OTHER INFORMATION Provide an estimate or actual number of deaths, BLOCK M:

    injuries, and persons hospitalized as a result of the disaster. If you have

    confirmed the numbers, place a “C” after the figure.

    ADDITIONAL DISASTER INFORMATION This additional information BLOCK N:

    assists FEMA in determining the needs of the community.

    COMMENTS SECTION

    Be sure to utilize the Comments Section of this form. Additional information which may substantiate the need for assistance should be provided in this space.

    Keep all notes and supporting documentation as a basis for completion of this form. Be sure to refer to the Damage Assessment Guide, August, 1995, for additional information concerning assessment.

Updated: 2/25/04 Page 4 of 4

TAB C REPORTING DAMAGES (FORMS)

TAB C REPORTING DAMAGES (FORMS)

    TAB C REPORTING DAMAGES (FORMS)

    Ohio EMA Preliminary Damage Assessment

    Individual Assistance Worksheet Instructions

    As a member of the IA PDA Team, your mission is to quantify primary residences and businesses impacted by the disaster; and to record information regarding the severity and magnitude of the event. The attached worksheet has been designed to be used in the field to record observed damages. For additional guidance on conducting an IA damage assessment, please refer to the EMA Preliminary Damage Assessment Field Guide or the Assistance

    Toolbox, developed and distributed by the Ohio EMA.

Block A: Location

    Information regarding the location of damaged or impacted primary residences can be recorded in one of several ways. A structure or group of structures may be identified by an individual address, a block of addresses (i.e. 5500-5565 North Street), or the name of a complex or park (i.e. apartments, condominiums or mobile home park.) Please note, it is not necessary to capture each individual address. However, enough information should be provided that in the event of a joint Federal/State PDA, damaged structures can be easily revisited. In the case of businesses record the name of the business and street address. You may want to capture businesses on a separate worksheet for ease in reporting the total number of businesses impacted.

Block B: Type of structure

    Type of structure is defined as: single family (SF); mobile home (MH); apartment (apt); condominium (condo); or business (bus). Secondary homes are not quantified and should not be included in this section. However, information regarding impact to these structures should be provided under the comment section in Block D.

Block C: Status

    Status refers to whether the occupant(s) are owners (O) or renters (R).

Block D: Notes/ tally / miscellaneous

    This section is used for notes, comments and additional information. Access issues and information regarding impact to secondary residences should be reported here.

Block E: Depth of water

    This block is utilized when assessing flood damages. Two (2) entries are required. First, record the level of water that entered the structure. Next, indicate whether the water was in the stbasement (b) or entered the first floor (1) living area.

Block F: Habitability

    There are 4 degrees of damage: destroyed, major, minor and affected. Please reference the EMA Preliminary Damage Assessment Field Guide for examples and illustrations of each of

    these categories. Based on criteria, record the degree of damage for each structure.

Block G: Insurance

    It is important to determine the extent of applicable insurance coverage. In a flooding event, you will want to determine whether the occupants carry flood insurance. For a wind event, it is important to note applicable homeowners insurance.

Block H: Totals

    Two sets of numbers are required. First, add the total number of primary residences for each degree of damage. Then, do the same for businesses. Report your findings to the designated point of contact.

TAB C REPORTING DAMAGES (FORMS)

TAB C REPORTING DAMAGES (FORMS)

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