Local Situation Report Form

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Local Situation Report
Submit as soon as possible after the initial emergency. Update daily and/or when significant changes occur.
Community: __________________
County: __________________
Date/Time Report Prepared: ____________________________________
Initial Report
Status Update
Final Report
Follow-up Required
Community Contact Information:
Reported by: ____________________
Title: ____________________
Call back #: _____________________
Fax: _____________________
Email: _____________________________________________________
Emergency Type: ______________________________________________
(
Flood, Haz-Mat, Tornado, Earthquake, Other)
: _______________________________________
Boundaries of Affected Area
_______________________________________
(Use roads, streams, major landmarks, jurisdictional boundaries, ect.)
Local Emergency Declared?
Yes
No
Status of Local EOC?
Open
Closed
Partial
Estimated # of households affected: _______
Are local mutual aid agreements being utilized?
Yes
No
Estimated # of people affected: _____
Local Situation Report
Submit as soon as possible after the initial emergency. Update daily and/or when significant changes occur.
Community: __________________
County: __________________
Date/Time Report Prepared: ____________________________________
Initial Report
Status Update
Final Report
Follow-up Required
Community Contact Information:
Reported by: ____________________
Title: ____________________
Call back #: _____________________
Fax: _____________________
Email: _____________________________________________________
Emergency Type: ______________________________________________
(
Flood, Haz-Mat, Tornado, Earthquake, Other)
: _______________________________________
Boundaries of Affected Area
_______________________________________
(Use roads, streams, major landmarks, jurisdictional boundaries, ect.)
Local Emergency Declared?
Yes
No
Status of Local EOC?
Open
Closed
Partial
Estimated # of households affected: _______
Are local mutual aid agreements being utilized?
Yes
No
Estimated # of people affected: _____
Public Roadway Status
Community: __________________
County: __________________
Roadway:
Closed
Partial
Emergency
Re-opened
Vehicles
(Include numerical or
Only
Geographical reference)
Mass Care/Sheltering Information:
Community: __________________
County: __________________
If residents are utilizing a shelter in another community:
Name of Facility: _________________________________
Host Community: ________________________________
# of Residents Sent: _______________________________
If your community has established a shelter:
Shelter Type:
Local
Red Cross
Site Name: ___________________________________________________________
Site Address: _______________________ Site Phone: ________________________
Space Description: _____________________________________________________
(i.e. Gymnasium, Cafeteria, ect.)
Site Capacity:_____________________
Kitchen Facilities?
Yes
No
The following information is up to date as of: ______________________
Current Occupancy: ___________________________________________
Communities this shelter is serving:
_____________________________________________________________
Facility is being used for:
(Check all that apply)
Temporary Shelter
Warming/Cooling Station
Food Service
Sleeping
Other:
Shelter Point of Contact:
Name: ____________________________
Title: _____________________________
Direct Telephone: __________________

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