Initial Supplemental

Disaster Assessment Summary

 

  1. Jurisdiction(s) Affected______________________________________Date:___________
  1. Disaster: Type______________________________ Date_______________ Time_______
  2. Report by: Name___________________________________ Title_____________________

    3. Work Phone_____________________ Home Phone______________________

  3. Affected Individuals: (Assign affected individuals to only one category.)
a. Fatalities   d. Missing  
b. Injuries   e. Evacuated  
c. Hospitalized   f. Sheltered  

 

5. Property Damage:

  1. Residence
  # Destroyed #Major #Minor #Inaccessible # Insured
Single Family          
Multi Family          
Mobile Homes          

 

Estimated Losses to Residence $__________

  1. Business
    2. # Destroyed # Major # Minor # Insured
           

    Estimated Loss to Business $_____________

  2. Public Facilities
Type of Work or Facility

Categories

 Estimate # of Sites Brief Description of Damages
  1. Debris Removal
    2.
$    
  • Protective Measures
 $    
  • Roads & Bridges
 $    
  • Water Control
 $    
  • Buildings Equipment
 $    
  • Utilities
 $    
  • Parks and Recreations
 $    

Total Estimate

 $

SEMA fax number – (573) 634-7966

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