Form: BC Initial Impact Assessment Form_Initial.html,BC Initial Impact Assessment Form_Viewer.html seqinc: To: Subj: //WL2K / Msg # INITIAL IMPACT ASSESSMENT Msg: Precedence: Message Number: Base Call of Sender: Place of Origin: , BC Time (local): Date (local): To Name: PREOC Operations Organization: EMBC ==================================================================== INITIAL IMPACT ASSESSMENT REPORT ==================================================================== 1A) Is EOC activated? 1B) EOC Activation Status? 1C) State of Local Emergency Declared? 1D) EOC Comments: 1E) First Responders Functional? 2) Priority Needs (3 only) 1) 2) 3) 3A) Number of people displaced: 3B) Number of people injured: 3C) Number of fatalities: 3D) Have people been evacuated? 3E) Number of people evacuated: Critical Infrastructure Impacted ______________________________________________ 4A) Water: - - (ETR) 4B) Sanitation: - - (ETR) 4C) Gas: - - (ETR) 4D) Electricity: - - (ETR) 4E) Telephone: - - (ETR) 4F) Internet: - - (ETR) 4G) Cellular Network: - - (ETR) 4H) Text Messaging: - - (ETR) 4I) SAT Phone: - - (ETR) 4J) Amateur Radio Station Status: (ETR) Callsign: Winlink address: ______________________________________________ 5A) If potable water system is unusable, estimated days remaining of water: 5B) Estimated days remaining of food: 5) Primary Transportation Route: 7) Medical - Hospitals/Clinics: 8A) Shelter - estimated % of homes uninhabitable: 8B) Estimated percentage of Rapid Damage Assessment completed: 9) Comments: _____________________________________________________________________ Report Originator: Organization: Sender Call or Tactical: Message sent via the Winlink System Send reply to @winlink.org HTML BC Initial Impact Assessment Form