(OnLine Damage Report Form)

Collier County graphic COLLIER COUNTY EMERGENCY MANAGEMENT

OnLine Citizen's Damage Reporting Form

This form is intended to be used by Collier Assessment Reporting Team (CART) members, CERT teams and individual homeowners to report damages in a community affected by a natural hazard, such as, tornado, hurricane, severe weather. In an effort to better assess the impact of a damaging event in a timely fashion, we are testing this form as one of our means to gather information about the event. This process will not be replacing professional teams sent out to assess the impact of a disaster on a community; but it can augment our eyes in the community, especially when roadways are blocked. Your contact information will allow us to follow up on your report.

PLEASE COMPLETE THE FORM USING CAPITAL LETTERS. Click on "Please Transmit Report" at the end of this form to send it to the Emergency Management office.

Thank you.

Your name, or agency?

Your street address / subdivision?

Your city?

Your telephone number?

Are you a homeowner?

Are your losses INSURED?

If you are INSURED, have you seen your ADJUSTER?

Water utility out?

Sewer utility out?

Electric utility out?

Are you on WELL or SEPTIC system? (Otherwise,go to the next section "Damages Description")

Well system out?

Septic system out?

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DAMAGES DESCRIPTION: Select one item from each drop box. If you have several which apply, select the one which has the greatest impact and describe the rest in the "Comments" section below:

HOME DAMAGE - OUTSIDE:
HOME DAMAGE - INSIDE:
Do You Have FLOODING Damages?

IF FLOODING DAMAGE - DEPTH OF WATER INSIDE OF THE HOME (NOT PATIO):
Comments?
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INFRASTRUCTURE: State the conditions around the neighborhood, that is, blocked roadways, power/electrical lines down, etc. Use the "Comments" section for additional information.
ROADWAYS OPEN?
POWERLINES down in the neighborhood?

Comments?