Fema Form 078-0-1 Request For Fire Management Assistance Declaration Page 2

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DEPARTMENT OF HOMELAND SECURITY
O.M.B. No. 1660-0058
Expires: January 31, 2018
Federal Emergency Management Agency
REQUEST FOR FIRE MANAGEMENT ASSISTANCE DECLARATION
III. CURRENT THREAT
19. THREAT TO LIFE:
a. PREPARATIONS MADE FOR EVACUATION? b. PERSONS EVACUATED:
YES
NO
#
#
20. NAME AND LOCATION OF COMMUNITY THREATENED
ADDITIONAL INFORMATION
CITY
TOWN
SUBDIVISION
21. CASUALTIES
22. THREAT TO PRIVATE PROPERTY (Dwellings)
1. CIVILIAN LOSS OF LIFE
1. NUMBER OF HOMES
2. CIVILIANS INJURED
a. % OF PRIMARY
b. % OF SECONDARY
3. FIRE FIGHTERS LOSS OF
LIFE
4. FIRE FIGHTERS INJURED
23. THREAT TO FACILITIES (Include number when applicable)
AMOUNT
TYPE
AMOUNT
TYPE
BUILDINGS
RECREATION
ROADS & BRIDGES
EQUIPMENT
INFASTRUCTURE
BUSINESS
UTILITIES
OTHER
ADDITIONAL INFORMATION
24. THREAT TO RESOURCES
WATERSHED
WILDLIFE (Type threatened, fur-bearing animals, big game, etc.)
IRRIGATION
ENVIRONMENTAL RESOURCES (bio-diverse areas, etc.)
FLOOD CONTROL
CULTURAL RESOURCES
FISHING STREAMS & SPAWNING SITES
ECONOMIC INJURY
ADDITIONAL INFORMATION
IV. STATE ASSESSMENT
25. EMERGENCY MANAGEMENT ASSESSMENT OF THE SITUATION
DATE
SIGNATURE
26. FORESTRY ASSESSMENT OF THE SITUATION
DATE
SIGNATURE
FOR FEMA REGIONAL USE ONLY
TITLE
DATE
SIGNATURE
FEMA FORM 078-0-1 (08/14)
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