MAINE EMERGENCY MANAGEMENT AGENCY

FORM 7

DAMAGE and INJURY ASSESSMENT

rev May 1992

/_/ Original /_/ Revision # ________

Date:

Type of Disaster:

Date(s) of Occurrence:

Jurisdiction (town, county, agency, etc.):

County: HANCOCK

Area Affected (northeast, west side, etc.):

Information provided by:

Name:

Title:

Address:

Day Phone:

Evening Phone:

 

 

 

 

PUBLIC DAMAGE

A

DEBRIS CLEARANCE (roads, streets, public buildings, private property (heath hazard only), stream clearance and other*)

$

B

PROTECTIVE MEASURES (sandbagging, barricades, signs, extra police and fire, emergency health measures)

$

C

ROAD SYSTEMS (town or county roads, culverts, and bridges)

$

D

WATER CONTROL FACILITIES (town or county owned dikes, dams, levees, drainage channels, irrigation works and other*)

$

E 1

PUBLIC BUILDINGS, FACILITIES AND EQUIPMENT (town or county buildings, supplies, inventory vehicles and equipment)

$

E 2

SCHOOLS AND SCHOOL PROPERTY (public schools only)

$

F

PUBLIC UTILITY SYSTEMS (water, sanitary-sewage, storm drains, lights, power, and other*)

$

G

OTHER (town or county park facilities, recreational facilities, docks, wharfs and other*)

$

TOTAL PUBLIC DAMAGE

$

*If "Other", please explain on a separate sheet.

CALL or FAX THIS INFORMATION to your
COUNTY EMERGENCY
MANAGEMENT AGENCY
as SOON as POSSIBLE (BEFORE MAILING)

Hancock County EMA

50 State Street
Ellsworth, ME 04605

Tel: 667-8126,  Fax: 667-1406

E-mail - ema@co.hancock.me.us



INDIVIDUAL DAMAGE

FORM 7 Page 2

Jurisdiction:

Date:

PEOPLE AFFECTED

Number

ASSISTANCE PROVIDED

Number

Deaths

 

Persons Evacuated

 

Injuries

 

Persons in Public Shelters

 

Diseased

 

 

 

RESIDENTIAL

Secondary

Primary

 

Number

Value

Number

Value

Houses Destroyed

 

$

 

$

Houses severely damaged

 

$

 

$

Houses moderately damaged

 

$

 

$

Mobile homes destroyed

 

$

 

$

Mobile homes severely damaged

 

$

 

$

Mobil homes moderately damaged

 

$

 

$

TOTAL

 

$

 

$

TOTAL RESIDENTIAL (primary plus secondary

 

$

BUSINESS

Businesses affected

 

 

Number now unemployed

 

 

Estimated duration of unemployment (weeks)

 

TOTAL BUSINESS

$

AGRICULTURE

Farm buildings and equipment

$

Crop land (all crops)

$

Livestock

$

TOTAL AGRICULTURE

$

PRIVATE NON-PROFIT FACILITIES (churches, private schools, hospitals, cemeteries, utilities, etc.)

 

$

TOTAL INDIVIDUAL DAMAGE

$

TOTAL PUBLIC DAMAGE from page 1

$

GRAND TOTAL

$

CALL or FAX THIS INFORMATION to your
COUNTY EMERGENCY
MANAGEMENT AGENCY
as SOON as POSSIBLE (BEFORE MAILING)

Hancock County EMA

50 State Street
, Ellsworth, ME 04605

Tel: 667-8126 Fax: 667-1406  

e-mail - ema@co.hancock.me.us

 

 



MAINE EMERGENCY MANAGMENT AGENCY

DAMAGE AND INJURY ASSESSMENT FORM 7

ABBREVIATED INSTRUCTIONS

Reasonable estimates are acceptable. Information should be reported to your County Emergency Management Agency (EMS) within 24 hours of a request for information from our county EMA or the Maine Emergency Management Agency (MEMA). Even if you consider damage in your area to be insignificant, please file this report. A complete picture of the impact of the disaster is necessary for State officials to decide if Federal assistance can be requested. Failure or delay in submission of this information may result in delay or loss of Federal assistance for your county and community.

Only sections needing further explanation are included in this document. If you need further assistance, contact your County EMA or MEMA.

General Information

Original or Revision: Check one only. Each report should contain the current totals (all the damage up to that point Number each revised report consecutively, i.e., first revision #1, second revision #2, etc.).

Type of Disaster: Enter "flooding", "hurricane", "coastal storm", etc.

Information provided by: Person who should be contacted for more information.

Public Damage

Public damages are damages to government-owned properties and facilities. They are based on the cost of returning those properties to their pre-disaster condition. They also include out-of-pocket costs incurred by government in response to the disaster.

  • Debris Removal: The debris must be a direct result of the disaster. Enter costs incurred or projected for removing debris from public property. Do not include debris removal estimates from private property, unless local government has a legal responsibility to do so. Include actual and estimated costs to remove debris from public roads and streets in your jurisdiction.
  • Protective Measures: These can include the cost of search and rescue, demolition of unsafe structures, and actions taken by governmental forces to reduce the threat to public health and safety. The disaster must be responsible for your extra costs.
  • Road Systems: Cost to return property to its pre-disaster condition. Include only property owned by the jurisdiction (do not include any State or Federal Aid System roads, streets, bridges, etc).
  • Water Control Facilities: Facilities owned, operated, controlled, or maintained by the local unit of government.

E1. Public Buildings, Facilities and Equipment: This should include any equipment directly damaged by the disaster (not those damaged during response), replacement of broken windows, damaged roofs, etc.

E2. Schools and School Property: Separate public schools, supplies and school property from other public facilities and equipment. Do not include private, non-profit schools. They are included under Individual Damage.

  • Public Utility Systems: Enter all costs to repair damages to town or conty owned utilities and utility systems. These can be the emergency repair and/or projected permanent replacement costs.

Total Public: Add totals in all public categories.

Maine Emergency Management Agency Form 7 Abbreviated Instructions

Individual Damage

Individual damages are damages to individuals, business and working farms (crops, livestock, buildings or

equipment), and private non-profit facilities (for example, churches or private schools).

NOTE: Re-enter name of jurisdiction and current date at top of Page 2.

Residential: Primary homes are those used as reference for filing income taxes and voting. Homes may be considered "primary" which are necessary because of the location of employment. Secondary homes are usually vacation homes. If a secondary home is rented out, then damage to it would be listed under Business. Estimated values are acceptable. (Do not list homes situated on active farms in this section. They will be included under Agriculture.)

Destroyed: Totally uninhabitable and beyond repair

Severely Damaged: Structural damage that cannot be repaired within 30 days. These houses are uninhabitable without major structural repairs.

Moderately Damaged: Structural damage that can be repaired within a 30 day time period. These houses can be lived in with minor reparis.

Note: The Red Cross does not categorize major/minor damage in the same manner. You should be aware of this if you decide to utilize their damage assessment.

Mobile Homes: Use Same categories of damage as houses above. Water above the floor of a mobile home for any significant length of time generally causes severe damage to it, even though some occupants my choose to move back in.

NOTE: Report numbers of homes damaged even if you do not at present know the value.

Total Residential: Include both Primary and Secondary Residences.

Business: Number Now Unemployed: Include only those who are unemployed due to the disaster. This can be the result of either business damage or their inability to travel to that business.

Agriculture: Include operating farms only. Damage to a rurally located "farmhouse" and/or outbuildings that are not part of an operating farm should be listed under Residential.

Crop Land: Estimated dollar value of damage to field crops, fruit trees, and timberlands significantly damaged by the disaster.

Private Non-Profit Facilities: Do not include facilities supported by tax dollars and the responsibility of government. They should be listed in the Public Damage section.

Total Individual: Add Total Residential, Total Business, Total Agriculture and Total Private.

GRAND TOTAL: Add Total Individual Damage and Total Public Damage.













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