SITUATION REPORT
Today's Date
-
Month
-
Day
Year
Date
Type of Emergency
Flood
Fire
Structure
Other
Home Visit Type
Resident Present
Resident not available
Worker Name
First Name
Last Name
Worker Phone Number
-
Area Code
Phone Number
Worker's Email
example@example.com
Worker's Agency
Red Cross
County Agency
City Agency
Other
Household Information
Customer Full Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address of Incident
*
Street Number
Street Name
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Residence Type
Primary Resisdence
Secondary Residence
Structure Type
Single Family Unit
Multiple Family Unit
Mobile Home
Household Status
Owns
Rents
Languages spoken in the household
English
Spanish
Creole
Other
How many dependents do you have living with you?
Please Select
None
1
2
3
4
5
Full Name of Dependent 1
First Name
Last Name
Relationship to you
Full Name of Dependent 2
First Name
Last Name
Relationship to you
Full Name of Dependent 3
First Name
Last Name
Relationship to you
Full Name of Dependent 4
First Name
Last Name
Relationship to you
Full Name of Dependent 5
First Name
Last Name
Relationship to you
What type of pets are in the residence?
None
Dogs
Cats
Birds
Fish
Exoctic
Other
Household Income
Employment Wages
SSI/SSD
Child Support
Retirement/Pension
Other
What type of assistance are you receiving
None
Food Stamps
Subsidized Housing
TANF
Other
Estimated Monthly Household Income
Insurance Coverage
None
Homeowners
Homeowners with Flood
Renters
Not Sure
Are you a veteran?
YES
NO
Do you have friends or family living locally?
YES
NO
Do you have a place to stay tonight?
*
YES
NO
Do you or anyone you reside with have a disability?
YES
NO
Do you or anyone you reside with have any medical considerations?
YES
NO
Do you have transportation?
YES
NO
DAMAGE SUMMARY
Date of Incident
-
Month
-
Day
Year
Date Picker Icon
Affected
Minor Damages
Major Damages
Destroyed
Housing Conditions
Habitable
Uninhabitable
Inaccessible
Cause for Displacement
Water Level in Structure (in feet)
Replace Cost or Market Value
Estimated Dollar Loss Market Value
Submit
Follow Up Information
Actions Taken
Please list agency name next to the action
Status
Closed
Open
Submit
Should be Empty: