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DAMAGE:
ROOM ASSESSMENT FORM
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Storm/Event: |
Assessment Date: |
Room
Number: |
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Building
Name: |
Building
Number: |
Mark if
update to previous form: _________ |
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Name of
Assessor: |
Control
Number: |
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CAUSE OF
DAMAGE: (Check One) |
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IMPACT
(Wind or Debris) |
WIND
(hit by tree or limb)
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Water
Damage (Rain or Leak)
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Power
Surge or Lightning
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Water
Damage (Flooding)
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Other
(describe) |
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DAMAGE DETAIL: |
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Contents/Items |
Description of Damages |
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Carpet/Flooring |
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Walls |
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Ceiling Tile |
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Windows |
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Furniture |
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Built-in Furniture |
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Lighting |
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HVAC |
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(Additional Items) |
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Emergency Repairs or Preventive Actions
(leave blank if no actions taken) |
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Action
Taken: |
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Name of
Person: |
Date of
Repair: |
Labor
Time (hrs.): |
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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.
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Name of
Person Submitting: |
Date: |
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Contact
Information: |
