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DAMAGE: BUILDING 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)
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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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Roof |
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Gutters |
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Entry |
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Stairs |
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Landscaping |
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Walls |
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Power |
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Elevators |
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Windows |
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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:
_____________________________
Contact Information:
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Date:
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