INITIAL IMPACT ASSESSMENT FORM           Vers 1.2

Location:

Precedence: R = Routine, P = Priority, O = Immediate, Z = Flash

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)
 

People Impacted (Estimated/Confirmed):

2A

# Displaced

2B

# Injured

2C

# Fatalities

2D Evacuations? 2E

# Evacuated


Critical Infrastructure

Provide impact description and Estimated Time to Repair (ETR)

  Impacted? Comments ETR
3A Water
3B Sanitation
3C Gas
3D Electricity
3E Telephone
3F Internet
3G Cellular Network
3H Text Messaging
3I SAT Phone

Amateur Radio Station

3J) Status: ETR:
  Callsign:
  Winlink address:

4A) If potable water system is unusable, estimated days remaining of water:

4B) Estimated days remaining of food:

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

6) Medical - Hospitals/Clinics:  
 

7A) Shelter - estimated % of homes uninhabitable:

7B) Estimated percentage of Rapid Damage Assessment completed:

8) Priority Needs (3 only)
    1)
    2)
    3)

9) Comments:
 

Report Originator:

Organization:

Functions
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