Form: Uniform Disaster Situation Report.html,Uniform Disaster Situation Report Viewer.html
To:
Subject:UNIFORM DISASTER SITUATION REPORT - ,
Msg:
WISCONSIN EMERGENCY MANAGEMENT
DEPARTMENT OF MILITARY AFFAIRS
UNIFORM DISASTER SITUATION REPORT
NAME OF PERSON SUBMITTING REPORT:
STREET ADDRESS:
CITY: ST: ZIP:
PHONE NO:
EMAIL:
TYPE OF INCIDENT:
DATE & TIME OF INCIDENT:
DATE REPORTED:
VERSION:
LOCATION OF INCIDENT
WEM REGION:
COUNTY:
OTHER LOCATION DETAILS (ATTACH A MAP SHOWING LOCATIONS):
CITY:
TOWNSHIP:
VILLAGE:
ESTIMATED NUMBER OF INDIVIDUALS IMPACTED
SHELTERED:
DEATHS:
INJURIES:
HOMELESS:
EVACUATED:
PRIVATE SECTOR DAMAGE ESTIMATES
ESTIMATED NO. OF RESIDENTIAL HOMES
AFFECTED:
MINOR:
MAJOR:
DESTROYED:
TOTAL RESIDENTIAL:
ESTIMATED DOLLAR AMOUNT: $
PERCENT COVERED BY INSURANCE : %
ESTIMATED NO. OF BUSINESSES
AFFECTED:
MINOR:
MAJOR:
DESTROYED:
TOTAL BUSINESS:
ESTIMATED DOLLAR AMOUNT: $
PERCENT COVERED BY INSURANCE: %
FARM BUILDINGS DAMAGED?
CROPS AFFECTED?
LIVESTOCK LOST?
TOTAL AGRICULTURAL COSTS: $
TOTAL PRIVATE SECTOR DAMAGE: $
PUBLIC SECTOR DAMAGE ESTIMATES
A) DEBRIS CLEARANCE: $
B) PROTECTIVE MEASURES: $
C) ROAD SYSTEMS: $
D) WATER CONTROL FACILITIES: $
E) PUBLIC BLDGS & RELATED EQUIPMENT: $
F) PUBLIC UTILITY SYSTEMS: $
G) OTHER: $
TOTAL PUBLIC SECTOR DAMAGE: $
DESCRIBE LOCAL ACTIONS TAKEN OR TO BE TAKEN. INCLUDE NAMES AND PUBLIC OFFICIALS INVOLVED IN THE RESPONSE EFFORTS.
DESCRIBE OUTSIDE ASSISTANCE NEEDED OR BEING REQUESTED.
ADDITIONAL COMMENTS (INCLUDE ECONOMIC OR OTHER IMPACTS ON AFFECTED COMMUNITIES).
DOES THE COUNTY INTEND TO APPLY FOR ASSISTANCE FROM THE WISCONSIN DISASTER FUND?
Form WEM-0002
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