Damage Assessment / Windshield Survey Work Sheet

Print as many copies as needed. Used to gather field info to bring back to radio operator to compile and send.

 
 Jurisdiction ________________________________  Date Of Survey ___________________

Survey Area   ________________________________ Survey Team   ______________________________

Affected
10 %		 Minor
25 %		 Major
50 %		 Totaled
100 %		 Total
Number		 $ Loss 
CATEGORY                                                    # # # # Count $ Estimate
HOUSES
 
APARTMENT COMPLEX
 
MOBILE HOMES
 
RESIDENTIAL HIGH RISE BUILDING 
 
COMMERCIAL HIGH RISE BUILDING
 
PUBLIC BUILDINGS
 
SMALL BUSINESS
 
FACTORIES / INDUSTRIAL COMPLEX
 
ROADS
 
BRIDGES
 
ELECTRICAL DISTRIBUTION
 
SCHOOLS
 
 
 
 
Total Dollar Amount:
 

COMMENTS (if any by the survey team)