State Emergency Management Agency

Completion Instructions

SUMMARY:

This form is intended to provide local jurisdictions with a standard method of reporting initial and supplemental damage estimates to SEMA. This information will be used to assess the situation throughout the affected area. It will also be combined with other reported information and used to help decide on future actions.

These forms are intended to be cumulative. If you submit additional reports, all of the columns MUST show current totals. For example, if the first form you submitted showed sixteen residential structures damaged and you identify four more damaged residential structures, the next form you submit MUST show twenty damaged residential structures.

1. Jurisdiction(s) Affected: Please include the name of the area affected, including county, and date of report.

2. Disaster: List the type, time and date of incident.

3. Report by: List name of person submitting report, his/her title, home and work phone numbers. This person will be SEMA’s point of contact for additional information.

4. Affected Individuals: List affected individuals based on the category the individual fits in. Please assign individuals to only one of the six categories. For example, do not assign someone to the "injuries" category if they are already assigned to "hospitalized".

1. Residence: List the number of residential properties damaged as a result of the disaster (separated either by single family, multi family or mobile homes) in the categories provided. Provide a total dollar amount in estimated losses to residences.
2. Business: List the number of business properties damaged as a result of the disaster in the categories provided. Provide a total dollar amount in estimated losses to businesses.
3. Public Facilities: List the estimate in dollars, the number of sites, and a brief description of damages in the six categories under Type of Work or Facility. Provide a total dollar amount in estimated losses to public facilities.

Remember: The SEMA Logo on the top of the form means to send it to SEMA upon completion.

Summary Form

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