INITIAL IMPACT ASSESSMENT FORM           Vers 1.2
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Location:

  Exercise Report
  Regular (Actual Report)
 
Precedence:
  Immediate
 

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)
 

People Impacted (Estimated/Confirmed):

2A

# Displaced

 2B

# Injured

 2C

# Fatalities

 2D Evacuations? 2E

# Evacuated

Critical Infrastructure

Provide impact description and Estimated Time to Repair (ETR)

  Impacted? Comments ETR
3A Water
3B Sanitation
3C Gas
3D Electricity
3E Telephone
3F Internet
3G Cellular Network
3H Text Messaging
3I SAT Phone

(Include SAT phone number in comments)

Amateur Radio Station

3J) Status:
On Air    
Damaged ETR:
  Callsign:
  Winlink address:

4A) If potable water system is unusable, estimated days remaining of water:

4B) Estimated days remaining of food:

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

6) Medical - Hospitals/Clinics:  
 

7A) Shelter - estimated % of homes uninhabitable:

7B) Estimated percentage of Rapid Damage Assessment completed:

8) Priority Needs (3 only)
    1)
    2)
    3)

9) Comments:
 
Report Originator:

Organization:

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