APPENDIX F

DAMAGE: BUILDING 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

Roof

 

Gutters

 

Entry

 

Stairs

 

Landscaping

 

Walls

 

Power

 

Elevators

 

Windows

 

(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:  _____________________________

Contact Information: 

Date:

 

 

 

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