Preliminary Damage Assessment

Priminary Damage Assessment (form DA-X-2)
Name of Jurisdiction: Population: County: Population: Report Date:

9/6/2019
Type of Disaster: Disaster Date: Area Primarily Affected:
Contact Name: Title:
Address: Phone (Desk):
Email Address: Phone (Cell):
Public Assistance (PA) - Damage to government buildings, property, or infrastructure.

A. Debris Clearance E. Public Buildings, Facilities, Equipment
Public Roads and Streets $0 Public Buildings Destroyed 0 $0
Public Property $0 Public Buildings Damaged 0 $0
Other $0 Building Contents $0
Vehicles / Equipment $0
Insurance Coverage 0.00%
Total $0 Total $0
B. Protective Measures F. Public Utilities (Publicly Owned)

Emergency Temporary Repairs $0 Water Distribution Systems $0
Flood Protection / Sandbagging $0 Water Treatment Plants $0
Barricades, Signs $0 Sewage Treatment Plants $0
Security / Search and Rescue $0 Sewers - Length in Feet 0 $0
Emergency Shoring $0 Other $0
Other $0 Insurance Coverage 0.00%
Total $0 Total $0
C. Road Systems Miles Dollars G. Parks and Recreational

Roads (miles 2-4 lanes) 0 $0 Parks $0
Roads (miles 6+ lanes) 0 $0 Recreational $0
Roads (other) 0 $0 Other $0
Bridges Destroyed 0 $0
Bridges Damaged 0 $0
Culverts Destroyed 0 $0
Culverts Damaged 0 $0 Insurance Coverage 0.00%
Total $0 Total $0
D. Water Control Facilities H. Schools and Private Non-Profit Facilities

Dikes $0 Public Schools Destroyed 0 $0
Levees $0 Public Schools Damaged 0 $0
Dams $0 Other Schools Destroyed 0 $0
Storm Drains $0 Other Schools Damaged 0 $0
Flood Control Channels $0 Private Utility $0
Catch Basins $0 Other $0
Other $0
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Insurance Coverage 0.00%
Total $0 Total $0
GRAND TOTAL $0
I. Current Jurisdiction Budget Information
Annual Budget Road Budget
Public Works Budget Date Fiscal Year Begins
Individual Assistance (IA) - Damage to private homes/property. Small Business Administration (SBA) Loan Damages
J. Individual K. Business / Industry
Residences Destroyed - Single Family 0 Businesses Destroyed 0
Residences Destroyed - Multi-Family 0 Businesses - Major Damage 0
Residences Destroyed - Mobile Home 0 Businesses - Minor Damage 0
Residences Damaged - Single Family 0 Businesses - Affected 0
Residences Damaged - Multi-Family 0 Number of Employees 0
Residences Damaged - Mobile Home 0 Days of Unemployment 0
Residences - Minor Damage 0 Insurance Coverage 0.00%
Residences - Affected 0
Insurance 0.00%
Total 0 Total 0
Agricultural Damage
L. Agriculture
Farm Buildings Destroyed 0 Crops - Acres Destroyed 0
Farm Buildings Damaged 0 Crops - Acres Damaged 0
Machinery / Equipment Destroyed 0 Livestock Destroyed 0
Machinery / Equipment Damaged 0 Livestock Injuried 0
M. Other Information (Unofficial Numbers*) N. Additional Disaster Information

Deaths If a FLOOD or WINTER STORM: Quanity - Inches
Injuried Hours Duration?
Hospitalized If FLOOD, Type:
Evacuated Stream Overflow?
Sheltered Sheet Flow?
Missing Sewer Backup?
Other?
* These numbers are unofficial only and should How long under water?
never be released to the media. They are for Chemical Contamination?
internal response planning purposes only. What Chemicals?
O. Additional Comments:
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Debris Clearance Emergency Protective Measures
Debris Clearance Protective Measures

Security, Search &
Roads & Streets $ Public Property $ Other $ Temporary Repair $ Flood Protection $ Barricades, Signs $ Shoring $ Other $
# Address / Location / GPS Rescue$ Description of Damage
1 Location 1 $0
2 Location 2 $0
3 Location 3 $0
4 Location 4
5 Location 5 $0
6 Location 6 $0
7 Location 7 $0
8 Location 7 $0
9 Location 9 $0
10 Location 10 $0
11 Location 11 $0
12 Location 12
13 Location 13 $0
14 Location 14 $0
15 Location 15 $0
16 Location 16 $0
17 Location 17 $0
18 Location 18 $0
19 Location 19 $0
20 Location 20 $0
21 Location 21 $0
22 Location 22 $0
23 Location 23 $0 $0
24 Location 24 $0
25 Location 25 $0
26 Location 26 $0
27 Location 27 $0
28 Location 28 $0
29 Location 29 $0
30 Location 30 $0
31 Location 31 $0
32 Location 32 $0
33 Location 33 $0
34 Location 34 $0
35 Location 35 $0
36 Location 36 $0
37 Location 37 $0
38 Location 38 $0
39 Location 39 $0
40 Location 40 $0
41 Location 41 $0
42 Location 42 $0
43 Location 43 $0
44 Location 44 $0
45 Location 45 $0
46 Location 46 $0
47
48
49
50
51
52
53
54
55
56
57
58
59
60
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Debris Clearance Emergency Protective Measures
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99
100
$0 $0 $0 $0 $0 $0 $0 $0 $0 0
Debris Clearance Protective Measures
# Address / Location Roads & Streets $ Public Property $ Other $ Temporary Repair $ Flood Protection $ Barricades, Signs $ Security & SAR $ Shoring $ Other $ Destroyed #

Roads and Bridges
Roads Bridges Destroyed Bridges Damaged Culverts Destroyed Culverts Damaged

# Type Miles Damaged $ Damaged Bridge Type # $ # $ # $\ # $
Address / Location / GPS
1 Location 1
2 Location 2
3 Location 3
4 Location 4
5 Location 5
6 Location 6
7 Location 7
8 Location 7
9 Location 9
10 Location 10
11 Location 11
12 Location 12
13 Location 13
14 Location 14
15 Location 15
16 Location 16
17 Location 17
18 Location 18
19 Location 19
20 Location 20
21 Location 21
22 Location 22
23 Location 23
24 Location 24
25 Location 25
26 Location 26
27 Location 27
28 Location 28
29 Location 29
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Roads and Bridges
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100 0 0 0 0 0 0 0 0 0 0 0
Roads Bridge Type Bridges Destroyed Bridges Damaged Culverts Destroyed Culverts Damaged
# Address / Location Type Miles Damaged $ Damaged # $ # $ # $\ # $
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Water Control Facilities
Flood Control
# Address / Location / GPS Dikes $ Levees $ Dams $ Storm Drains $ Channels $ Catch Basins$ Other $ Description of Damage
1 Location 1
2 Location 2
3 Location 3
4 Location 4
5 Location 5
6 Location 6
7 Location 7
8 Location 7
9 Location 9
10 Location 10
11 Location 11
12 Location 12
13 Location 13
14 Location 14
15 Location 15
16 Location 16
17 Location 17
18 Location 18
19 Location 19
20 Location 20
21 Location 21
22 Location 22
23 Location 23
24 Location 24
25 Location 25
26 Location 26
27 Location 27
28 Location 28
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55

Water Control Facilities
56
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95
96
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98
99
100
$0 $0 $0 $0 $0 $0 $0 0
Flood Control
# Address / Location Dikes $ Levees $ Dams $ Storm Drains $
Channels $
Catch Basins Other $
Destroyed #

Public Buildings, Contents and Equipment
Public Buildings
Vehicles / Equipment
# Address / Location / GPS Destroyed # Destroyed $ Damaged # Damaged $ Building Contents $ $ Insured ?
1 Location 1
2 Location 2
3 Location 3
4 Location 4
5 Location 5
6 Location 6
7 Location 7
8 Location 7
9 Location 9
10 Location 10
11 Location 11
12 Location 12
13 Location 13
14 Location 14
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81
82
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84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
0 0 0 0 0 0 0
Public Buildings
Vehicles / Equipment
# Address / Location Destroyed # Destroyed $ Damaged # Damaged $ Building Contents $ $ Insured ?

Public Utilities
Water Distribution Lineal Feet of

# Address / Location / GPS Systems $ Water Plants $ Sewage Plant $ Sewer Line Sewer Line $ Other $ Insured ? Description of Damage
1 Location 1 Yes
2 Location 2 No
3 Location 3 Unknown
4 Location 4
5 Location 5
6 Location 6
7 Location 7
8 Location 7
9 Location 9
10 Location 10
11 Location 11
12 Location 12
13 Location 13
14 Location 14
15 Location 15
16 Location 16
17 Location 17
18 Location 18
19 Location 19
20 Location 20
21 Location 21
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Public Utilities
51
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98
99
100
$0 $0 $0 $0 $0 $0 0

Public Utilities
Water Distribution Lineal Feet of

# Address / Location Systems $ Water Plants $ Sewage Plant $ Sewer Line Sewer Line $ Other $ Insured ?
Destroyed #

Parks and Recreation
# Address / Location / GPS Parks $ Recreational $ Other $ Insured ? Description of Damage

1 Location 1
2 Location 2
3 Location 3
4 Location 4
5 Location 5
6 Location 6
7 Location 7
8 Location 7
9 Location 9
10 Location 10
11 Location 11
12 Location 12
13 Location 13
14 Location 14
15 Location 15
16 Location 16
17 Location 17
18 Location 18
19 Location 19
20 Location 20
21 Location 21
22 Location 22
23 Location 23
24 Location 24
25 Location 25
26 Location 26
27 Location 27
28 Location 28
29 Location 29
30 Location 30
31 Location 31
32 Location 32
33 Location 33
34 Location 34
35 Location 35
36 Location 36
37 Location 37
38 Location 38

39 Location 39
40 Location 40
41 Location 41
42 Location 42
43 Location 43
44 Location 44
45 Location 45
46 Location 46
47 Location 47
48 Location 48
49 Location 49
50 Location 50
51 Location 51
52 Location 52
53 Location 53
54 Location 54
55 Location 55
56 Location 56
57 Location 57
58 Location 58
59 Location 59
60 Location 60
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$0 $0 $0 0
# Address / Location Parks $ Recreational $ Other $ Insured ?
Destroyed #

Schools and Nonprofits
Public Schools Other Schools

Public Schools Public Schools Public Schools Public Schools Other Schools Other Schools Other Schools Other Schools
# Address / Location / GPS Destroyed # Destroyed $ Damaged # Damaged $ Destroyed # Destroyed $ Damaged # Damaged $ Private Utility $ Other $ Insured ? Description of Damage
1 Location 1 Yes
2 Location 2 No
4 Location 4
5 Location 5
6 Location 6
7 Location 7
8 Location 7
9 Location 9
10 Location 10
11 Location 11
12 Location 12
13 Location 13
14 Location 14
15 Location 15
16 Location 16
17 Location 17
18 Location 18
19 Location 19
20 Location 20
21 Location 21
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Schools and Nonprofits
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100 0 0 0 0 0 0 0 0 0 0
Public Schools Other Schools 0
Public Schools Public Schools Public Schools Public Schools Other Schools Other Schools Other Schools Other Schools
# Address / Location Destroyed # Destroyed $ Damaged # Damaged $ Destroyed # Destroyed $ Damaged # Damaged $ Private Utility $ Other $ Insured ?
Destroyed #

Residences
Destroyed Single Destroyed Mulit- Destroyed Mobile Damaged Single Damaged Mulit- Damaged
# Address / Location / GPS Family # Family # Home # Family # Family # Mobile Home # Minor Damage # Affected # Insured ? Description of Damage
1 Location 1 Yes
2 Location 2 No
4 Location 4
5 Location 5
6 Location 6
7 Location 7
8 Location 7
9 Location 9
10 Location 10
11 Location 11
12 Location 12
13 Location 13
14 Location 14
15 Location 15
16 Location 16
17 Location 17
18 Location 18
19 Location 19
20 Location 20
21 Location 21
22 Location 22
23 Location 23
24 Location 24
25 Location 25
26 Location 26
27 Location 27
28 Location 28
29 Location 29
30 Location 30
31 Location 31
32 Location 32
33 Location 33
34 Location 34
35 Location 35
36 Location 36
37
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Residences
53
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100
0 0 0 0 0 0 0 0 0
Destroyed Single Destroyed Mulit- Destroyed Mobile Damaged Single Damaged Mulit- Damaged
# Address / Location Family # Family # Home # Family # Family # Mobile Home # Minor Damage # Affected # Insured ?
Destroyed #

Businesses
Businesses Businesses Major Businesses Businesses Businessess # Businesses # Days

# Address / Location / GPS Destroyed # Damage # Minor Damage # Affected # Insured ? Employees of No Work Description of Damage
1 Location 1 Yes
2 Location 2 No
4 Location 4
5 Location 5
6 Location 6
7 Location 7
8 Location 7
9 Location 9
10 Location 10
11
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Businesses
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86
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89
90

Businesses
91
92
93
94
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99
100
0 0 0 0 0 0 0 0
Businesses Businesses Major Businesses Businesses Businessess # Businesses # Days
# Address / Location Destroyed # Damage # Minor Damage # Affected # Insured ? Employees of No Work
Destroyed #

Agriculture
Farm Buildings Machinery/Equipment Acres of Crops Livestock

# Address / Location / GPS # Destroyed # Damaged # Destroyed # Damaged # Destroyed # Damaged # Destroyed # Injured Description of Damage
1 Location 1
2 Location 2
3 Location 3
4 Location 4
5 Location 5
6 Location 6
7 Location 7
8 Location 7
9 Location 9
10 Location 10
11 Location 11
12 Location 12
13 Location 13
14 Location 14
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Agriculture
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85
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89
90
91
92
93
94

Agriculture
95
96
97
98
99
100
0 0 0 0 0 0 0 0 0
Farm Buildings Machinery/Equipment Acres of Crops Livestock
# Address / Location # Destroyed # Damaged # Destroyed # Damaged # Destroyed # Damaged # Destroyed # Injured Destroyed #

Preliminary Damage Assessment

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Preliminary Damage Assessment

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Copyright:

Verfügbare Formate

Priminary Damage Assessment (form DA-X-2)

Name of Jurisdiction: Population: County: Population: Report Date:

Contact Name: Title:

Address: Phone (Desk):

Email Address: Phone (Cell):

Public Assistance (PA) - Damage to government buildings, property, or infrastructure.

B. Protective Measures F. Public Utilities (Publicly Owned)

C. Road Systems Miles Dollars G. Parks and Recreational

D. Water Control Facilities H. Schools and Private Non-Profit Facilities

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M. Other Information (Unofficial Numbers*) N. Additional Disaster Information

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Debris Clearance Protective Measures

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Roads Bridges Destroyed Bridges Damaged Culverts Destroyed Culverts Damaged

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# Address / Location Type Miles Damaged $ Damaged # $ # $ # $\ # $

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Water Distribution Lineal Feet of

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Water Distribution Lineal Feet of

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# Address / Location / GPS Parks $ Recreational $ Other $ Insured ? Description of Damage

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Public Schools Other Schools

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Businesses Businesses Major Businesses Businesses Businessess # Businesses # Days

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Farm Buildings Machinery/Equipment Acres of Crops Livestock

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