Windshield Survey Form PDF Details

It's important for organizations to understand their surroundings and the demographics of the people in their area. A windshield survey form is a great way to collect this data. By conducting a windshield survey, you can get an idea of the general makeup of an area. This information can then be used to inform marketing, business decisions, and more. In this blog post, we'll go over what a windshield survey is and how to create your own form. We'll also provide some examples of what you could include on your form.

QuestionAnswer
Form NameWindshield Survey Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswindshield survey community assessment example, geriatric windshield survey table, windshield survey example, 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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