INITIAL IMPACT ASSESSMENT FORM           Vers 1.4
Send to:

Location:

  Exercise Report
  Regular (Actual Report)
 
Precedence:
  Routine

1A) Is EOC Activated? 1B) EOC Activation status?
   
   

1C) State of Local Emergency Declared?
Yes No

1D) EOC Comments: (i.e. Number of staff /status of EOC etc)
 

1E) First Responders Status: (Include details pertaining to personnel and Apparatus)
 
2) Priority Needs (3 only)
    1)
    2)
    3)

 

People Impacted (Estimated/Confirmed):

3A

# Displaced

 3B

# Injured

 3C

# Fatalities

 3D Evacuations? 3E

# Evacuated

Critical Infrastructure

Provide impact description and Estimated Time to Repair (ETR)

  Impacted? Comments ETR
4A Water
4B Sanitation
4C Gas
4D Electricity
4E Telephone
4F Internet
4G Cellular Network
4H Text Messaging
4I SAT Phone (Include SAT phone number in comments)

Amateur Radio Station

4J) Status:
On Air    
Damaged ETR:
  Callsign:
  Winlink address:

5A) If potable water system is unusable, estimated days remaining of water:

5B) Estimated days remaining of food:

6) Primary Transportation Route - available into community and at least one alternate route:  
 

7) Medical - Hospitals/Clinics:  
 

8A) Shelter - estimated % of homes uninhabitable:

8B) Estimated percentage of Rapid Damage Assessment completed:


9) Comments:
 
Report Originator:

Organization:

   
Functions
Save Initial Impact Assessment data Save form data to disk that can be loaded later
Submit Create RMS Express message
Reset Form Delete all field entries