Post-Disaster Impact Assessment
Please fill out this form and click submit.
Disaster Event
Date of Specific Disaster Event:
*
Description of the specific disaster event:
*
Damaged Area
Describe the disaster impact in the damaged areas of your community. Use the following categories to
assist in your damage assessment.
Are homes damaged/ destroyed?
*
Please select all that apply.
Yes
No
Estimate how many homes are damaged/destroyed:
*
What neighborhoods/streets are these homes located in?
Estimate how many people have been impacted in these areas:
*
Is there a lot of debris in the damaged area?
*
Please select all that apply.
Yes
No
Some
Is debris blocking roads?
*
Please select all that apply.
Yes
No
Not Sure
Are there access restrictions in the damaged area? (only open to first responders, residents)
*
Please select all that apply.
Yes
No
Not Sure
Are there power outages? If so how widespread?
*
Please select all that apply.
Yes
No
Not Sure
If yes, how widespread?
Has community infrastructure been impacted? (Hospital, fire stations, schools)
*
Please select all that apply.
Yes
No
Not Sure
Has there been loss of life from this event?
*
Please select all that apply.
Yes
No
Not Sure
Are any of your staff impacted?
*
Please select all that apply.
Yes
No
Not Sure
Has your church been damaged?
*
Please select all that apply.
Yes
No
Not Sure
Are any of your properties affected residential facilities?
*
Please select all that apply.
Yes
No
Not Sure
Vulnerable Populations
Identify vulnerable populations in the damaged area, determine the ability to access resources, and identify
specific needs for assistance.
Have you identified specific needs for these vulnerable populations?
*
Please select all that apply.
Elderly
Homeless
Refugees
Undocumented/Migrants
Disabled
Single Parents
Do you have access to these basic needs:
*
Please select all that apply.
Food
Clean Water
Livable Sheltering
Personal Safety/Protection
Access to Medical Care (acute and chronic, medications)
Please tell us any additional information that could be helpful for ROA to know how to respond:
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Description
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