Initial:   Supplemental:

Date:             Time:              County:

Reported By:* 
Phone Number: *
Email Address: *

Has a county/city declared an emergency or disaster?  Yes  No

Describe in as much detail as possible what has happened or what you anticipate.   Include impact on individuals,
businesses and infrastructure.

When did it happen or when is it anticipated?

What actions have been taken?

What actions still need to be taken?

What resources outside of the jurisdiction may be needed? (Be specific)

  * These fields are required.