Natural Disaster Incident Report Form

This United States-specific printable "Natural Disaster Incident Report Form" is a part of the legal paperwork issued by the U.S. Environmental Protection Agency.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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Natural Disaster Incident Report Form
BACKGROUND INFORMATION
Met with
Name of Public Water System :
Name: __________________
Public water system (PWS ID) number:
Phone: __________________
PWS Phone #:
PWS Address:
Email: ___________________
Date of most recent site visit:
Date: ___________________
PWS Type: _CWS
_NCWS
_TNCWS
Time: ___________________
PWS Source: _GW _SW _Both _Purchased _Don’t Know
On site 
Contact made:
Population of PWS:
Phone 
Email
DAMAGE ASESSMENT INFORMATION
Is the water system in operation?
_Yes
_No
_Partial
_Don’t Know
Did the water system lose pressure?
_Yes
_No
_Partial
_Don’t Know
Power Loss:
_Yes
_No
_Don’t Know
Physical Damage:
_Yes
_No
_Don’t Know
Other:
Is the water system operating under a boil order?
_Yes _No
_Don’t know
If there is physical damage to the water system, identify the parts of the system that have been
damaged and the extent of the damage:
_Critical _Not Critical
Valves:
Pumps:
Electrical equipment:
Storage tanks:
Pipes:
SCADA:
Dams:
Vehicles:
Other:
This template report was provided via the U.S. EPA's website on Federal Funding for Utilities - Water/Wastewater - in National Disasters (Fed FUNDS).
For further information, please visit http://water.epa.gov/infrastructure/watersecurity/funding/index.cfm.
Natural Disaster Incident Report Form
BACKGROUND INFORMATION
Met with
Name of Public Water System :
Name: __________________
Public water system (PWS ID) number:
Phone: __________________
PWS Phone #:
PWS Address:
Email: ___________________
Date of most recent site visit:
Date: ___________________
PWS Type: _CWS
_NCWS
_TNCWS
Time: ___________________
PWS Source: _GW _SW _Both _Purchased _Don’t Know
On site 
Contact made:
Population of PWS:
Phone 
Email
DAMAGE ASESSMENT INFORMATION
Is the water system in operation?
_Yes
_No
_Partial
_Don’t Know
Did the water system lose pressure?
_Yes
_No
_Partial
_Don’t Know
Power Loss:
_Yes
_No
_Don’t Know
Physical Damage:
_Yes
_No
_Don’t Know
Other:
Is the water system operating under a boil order?
_Yes _No
_Don’t know
If there is physical damage to the water system, identify the parts of the system that have been
damaged and the extent of the damage:
_Critical _Not Critical
Valves:
Pumps:
Electrical equipment:
Storage tanks:
Pipes:
SCADA:
Dams:
Vehicles:
Other:
This template report was provided via the U.S. EPA's website on Federal Funding for Utilities - Water/Wastewater - in National Disasters (Fed FUNDS).
For further information, please visit http://water.epa.gov/infrastructure/watersecurity/funding/index.cfm.
PWS Name:
PWS ID#:
2
Incident Name:
Incident ID#:
Critical customers (List):
Being Served (Yes/No)? __
1. _________________________________________________________________
2. _________________________________________________________________
3. _________________________________________________________________
4. _________________________________________________________________
(Examples: Hospitals, Industries, Emergency Response Facilities, etc.)
OPERATOR INFORMATION
What are the water system’s current staffing levels?
Category
Normal Staffing Level
Current Staffing Level
Operators (certified)
Operators (not certified)
Administrative
Information Technology
GENERATOR
Does the system have back-up generation?
_Yes
_No
_Some
_Don’t know
How many generators does the system have? _____________________
Are generators currently in use:
_Yes _No _Don’t know
Fuel Type:
# of Days Supply:
Fuel Storage Capacity:
Do the generators allow the entire system to operate?
_Yes _No
_Don’t know
If No, Explain: ____________________________________________________________________
How long each day do you run each generator? __________________________________________
SOURCES
Name
Type
Condition
_ GW
_ SW
_ GW
_ SW
_GW
_ SW
This template report was provided via the U.S. EPA's website on Federal Funding for Utilities - Water/Wastewater - in National Disasters (Fed FUNDS).
For further information, please visit http://water.epa.gov/infrastructure/watersecurity/funding/index.cfm.
PWS Name:
PWS ID#:
3
Incident Name:
Incident ID#:
TREATMENT INFORMATION
Type of Disinfection used by Water System (Check all that apply):
Disinfectant Type
Pre-treatment
Primary
Booster
Operational
(yes/no)
Chlorination: gaseous
Chlorination: sodium hypochlorite
Chlorination: calcium hypochlorite
Chlorine Dioxide
Ozonation
UV
Chloramination
How many days supply of disinfectant does the water system currently have? ________________
Does System have filtration?
_Yes _No
_Don’t Know
Chemicals Used For Treatment
Days Supply Remaining
Next Expected Delivery Date
SAMPLING INFORMATION
Which of the following water quality parameters do you have capability to test (Circle all that apply)?
__pH
__Free Chlorine
__Total Chlorine
__Alkalinity __Turbidity
__Total Coliform
Other:
Additional description of State’s / water system’s response and results of water quality testing:
This template report was provided via the U.S. EPA's website on Federal Funding for Utilities - Water/Wastewater - in National Disasters (Fed FUNDS).
For further information, please visit http://water.epa.gov/infrastructure/watersecurity/funding/index.cfm.
OTHER SYSTEM RESPONSE MEASURES
Isolation:
_Yes _No
_Don’t Know
Emergency Booster Disinfection in Distribution System:
_Yes _No
_Don’t Know
Re-routing of water to customers:
_Yes _No
_Don’t Know
Discontinuation of service to customers:
_Yes _No
_Don’t Know
Have there been customer complaints reported:
_Yes _No
_Don’t Know
Emergency Interconnection:
_Yes _No
_Don’t Know
Is additional assistance from the EPA being requested at this time?
_Yes _No
(If yes, describe below)
FIELD TESTS
Additional Details/Notes
Any Additional Needs?
Pressure
Normal Range:
Average:
Field Test Result:
psi
Field Test Location:
Chlorine Residual
Normal Range:
Average:
Field Test Result:
Field Test Location:
Total Coliform
Number of samples:
Designated date and time for update and follow-up to missing info: __________________________
Signature of Water System Representative:
__________________________________________
(if present)
Signature of Assessor:
_______________________________________
Name of Assessor (printed):
_______________________________________
Today’s Date:
_______________________________________
This template report was provided via the U.S. EPA's website on Federal Funding for Utilities - Water/Wastewater - in National Disasters (Fed FUNDS).
For further information, please visit http://water.epa.gov/infrastructure/watersecurity/funding/index.cfm.

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