Damage Assessment Reporting


Please answer the following questions as completely and accurately as possible.
An American Red Cross Damage Assessment Team Member will follow up on all information provided.


Date:
Disaster Type:

If other describe:

Applicant's Name:

Family Name:

Street Number:

Street Name:

Apartment or Unit Number:

City:

County:

State: Florida
Home Phone Number:

Work Phone Number:

Alternate Phone Number:

* Primary E-Mail Address:
(* Required)

Secondary E-Mail Address:

Where can a Damage Assessment Team Member reach you?


Ownership:
Own     Rent
Insurance:
Homeowners    Personal Contents    Flood    Uninsured
Building Type:
Building Damage:

Description of
Building Damage:

Contents Damage:

Description of
Contents Damage:

Water Depth:
 inches above floor on first level
Number of floor levels:
Type of Use:

Electric Service:
Not Affected      Disrupted      Not Applicable
Water Service:
Not Affected      Disrupted      Not Applicable
Sewer Service
Not Affected      Disrupted      Not Applicable
Gas Service:
Not Affected      Disrupted      Not Applicable
Phone Service:
Not Affected      Disrupted      Not Applicable
Comments:


      

These items are to be completed by an American Red Cross Damage Assessment Team Member only
Disaster Relief Operation Name:

Team Member's Name:



PLEASE check all entries before submitting this report.
PLEASE DO NOT make multiple submissions of this report for the same residence

Disclaimer: The Capital Area Chapter of the American Red Cross will use this information for response activities to prioritize relief efforts. American Red Cross follows a very thorough process whereby resources are allocated to the most severly hit areas first.

Back to Capital Area Chapter of the American Red Cross

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