APPENDIX E

DAMAGE: ROOM ASSESSMENT FORM

 

Storm/Event:

Assessment Date:

Room Number:

Building Name:

Building Number:

Mark if update to previous form:  _________

Name of Assessor:

Control Number:

CAUSE OF DAMAGE:  (Check One)

IMPACT (Wind or Debris)           

WIND (hit by tree or limb)     

Water Damage (Rain or Leak)   

Power Surge or Lightning       

Water Damage (Flooding)          

Other (describe)

DAMAGE DETAIL: 

Contents/Items

Description of Damages

Carpet/Flooring

 

Walls

 

Ceiling Tile

 

Windows

 

Furniture

 

Built-in Furniture

 

Lighting

 

HVAC

 

(Additional Items)

 

 

 

Emergency Repairs or Preventive Actions (leave blank if no actions taken)

Action Taken:

 

Name of Person:

Date of Repair:

Labor Time (hrs.): 

Photograph: (Please attach)

Take digital photograph(s) of damages.  Include building name and room number on a piece of paper or dry erase board that is visible in photograph.

Name of Person Submitting: 

Date:

Contact Information:

 

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