Windshield Survey Form PDF Details

In the aftermath of a disaster, the assessment of damage stands as a critical first step towards the recovery and rebuilding of affected communities. The Windshield Survey Form serves as a pivotal tool in this endeavor, particularly for municipal authorities. Designed to document the extent of damage without venturing into monetary evaluations, this form categorizes damage into distinct levels ranging from 'Destroyed' to 'Minor'. The form is meticulous in its approach, covering a wide range of properties including but not limited to private residences, businesses, and public infrastructure such as bridges, hospitals, and schools. Furthermore, it distinguishes between flood and non-flood damage, providing specific criteria for each category. This categorization enables those responding to disasters to quickly gauge the severity of damage across different types of properties. Importantly, the form prompts municipalities to note the initiation of debris removal efforts and emergency protective measures, emphasizing its role not just in assessment, but in actioning initial recovery steps. By requiring completion and return within 24 hours post-event, it ensures a swift response, demonstrating its value in both planning and operational phases in the wake of emergencies. The detailed guidance provided underscores the importance of comprehensive documentation in expediting recovery processes, highlighting the form's utility in fostering resilience within communities.

QuestionAnswer
Form NameWindshield Survey Form
Form Length2 pages
Fillable?Yes
Fillable fields110
Avg. time to fill out22 min 34 sec
Other nameswindshield assessment example, windshield survey form, sample windshield survey, what is a windshield survey

Form Preview Example

 

WINDSHIELD SURVEY FORM

Municipality

 

EMC Name

Date / Time

 

For definitions of Reporting Categories, see back of form

 

 

Private

Property

Destroyed

Major

Minor

Affected

Inaccessible

Businesses

Mobile Home

Multi-Family

Single Family

 

For definitions of Reporting Categories, see back of form

Directions

 

Public

Destroyed

Affected

Damaged

 

 

Property

1) If damage has been sustained by

 

 

 

 

 

Bridges &

 

 

 

your municipality, document the

 

 

 

 

number of property types impacted in

 

Culverts

 

 

 

 

 

 

 

the appropriate column.

 

 

 

 

 

 

 

 

 

 

 

 

Fire / EMS Facility

 

 

 

2) DO NOT use this form to document

 

 

 

 

 

 

 

 

 

 

monetary estimates of damage, use

 

 

 

 

 

 

Hospital

 

 

 

number of properties only.

 

 

 

 

 

 

 

Nursing Home

 

 

 

 

 

 

 

 

 

3) If debris removal or emergency

 

Other

 

 

 

 

 

 

 

protective measures are in place, be

 

 

 

 

 

sure to complete the appropriate form

 

 

 

 

 

 

Park

 

 

 

and circle "Yes" to the questions listed

 

 

 

 

at the bottom of this form.

 

 

 

 

 

 

 

 

 

 

 

 

Power Supply

 

 

 

4) Complete this form and return to

 

 

 

 

 

 

 

 

 

 

Berks DES within 24 hours after the

 

Public Bldg (City

 

 

 

 

 

 

 

passing of the event.

 

Hall, Etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Roads

 

 

 

Berks County

 

 

 

 

 

 

Sanitary Sewer

 

 

 

Department of Emergency

 

 

 

 

Services

 

 

 

 

 

 

School

 

 

 

Phone

 

 

 

 

(610) 374-4800

 

 

 

 

 

 

Sewer Treatment

 

 

 

Fax

 

 

 

 

 

 

Storm Sewer

 

 

 

(610) 374-8865

 

 

 

 

 

 

 

 

 

 

berksdes@countyofberks.com

 

Water Control

 

 

 

 

Facility

 

 

 

 

 

 

 

 

 

 

 

Water Supply

 

 

 

 

 

 

 

 

 

 

 

Water Treatment

 

 

 

 

 

 

 

 

 

 

Are debris removal activities occurring in the municipality?

Yes

/

No

Are emergency protective measures in place in the municipality?

Yes

/

No

If "YES" is checked for either or both, complete "Protective Action/Debris Removal Form"

 

 

 

Non-Flood Damage Category Definitions

Affected

- Some shingles and/or siding missing

 

- Ingress / Egress to residence may be hampered

 

- Dwelling is livable without repairs

 

- IE: Stone driveway is washed away due to heavy rains

Damaged

- Property is usable, however repairs may be required

 

- Critical components of the facility are inoperable (pumps, electric, etc.)

 

- IE: Sewer Treatment is offline due to inoperable pumps

Destroyed

- Property is no longer there

 

- Property is structurally unsafe

 

- All major structural systems are damaged and habitation is not possible

 

- IE: Structure has partially collapsed

Inaccessible

- Unable to access property

 

- IE: Bridge out leading to property

Major

- Large portions of roof missing

 

- Structure or property cannot be used until repairs are made

 

- IE: Roof blown off due to high winds

Minor

- Property is damaged, but usable

 

- Numerous broken windows

 

- Minor structural damage

 

- IE: Roofing shingles blown off due to high winds

Flood Damage Category Definitions

 

 

AFFECTED

MINOR

MAJOR

 

DESTROYED

 

 

HOUSE

 

 

 

 

 

 

 

Crawl Space

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Basement

Less than 1'

1' or more

Extensive found.

 

 

 

 

damage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Floor

2" or less

Up to 2" but not affecting

1' or more

 

Physically

 

 

electric outlets

 

Destroyed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Slab House

2" or less

Up to 2" but not affecting

1' or more

 

Physically

 

 

electric outlets

 

Destroyed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Second Floor

 

 

X

 

Physically

 

 

 

 

 

Destroyed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOBILE HOME

No water into Belly

From Belly Board to

6" or more into

 

Physically

 

 

 

Board

6" on floor

mobile home

 

Destroyed

 

 

 

 

 

 

 

 

 

 

 

Quick Guide to Determining Damage Category

 

 

 

Is the STRUCTURE usable as it is?

 

 

 

YES

 

 

 

NO

 

Does it need temporary

 

 

 

Can it be made usuable again

 

repairs to be lived in now?

 

 

 

with extensive repairs?

 

Yes - Minor

 

 

 

Yes - Major

 

No - Affected

 

 

 

No - Destroyed

Revision 3 120808

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