Rapid Damage Assessment Data Input Form

Primary Frequency
Secondary Frequency
Date
Time Reported
Control Number
Incident Type
Sector
Collector's Name
Assessment Target
Access Route to Target

Life Safety Operations

Trapped
Number
Dead
Number
Injured
Number
Need
Evacuation
Number
to Evac.

Status of Lifelines

Electric
Functioning
Gas
Functioning
Sewer
Functioning
Water
Functioning
Telephone
Functioning

Description of Imminent Hazard


Other Major Problems

Additional Resources Required

SAR
Fire
EMS
Law Enforcement
Electric
Gas
Water
Public Works
Building and Safety
Transportation
Sheltering
Food

Other Disaster Intelligence Observed