Natural Disaster Incident Report Form
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4Natural Disaster Incident Report Form
BACKGROUND INFORMATION
Met with
Name of Public Water System :
Name: __________________
Public water system (PWS ID) number:
Phone: __________________
PWS Phone #:
PWS Address:
Email: ___________________
Date of most recent site visit:
Date: ___________________
PWS Type: _CWS
_NCWS
_TNCWS
Time: ___________________
PWS Source: _GW _SW _Both _Purchased _Don’t Know
On site
Contact made:
Population of PWS:
Phone
Email
DAMAGE ASESSMENT INFORMATION
Is the water system in operation?
_Yes
_No
_Partial
_Don’t Know
Did the water system lose pressure?
_Yes
_No
_Partial
_Don’t Know
Power Loss:
_Yes
_No
_Don’t Know
Physical Damage:
_Yes
_No
_Don’t Know
Other:
Is the water system operating under a boil order?
_Yes _No
_Don’t know
If there is physical damage to the water system, identify the parts of the system that have been
damaged and the extent of the damage:
_Critical _Not Critical
Valves:
Pumps:
Electrical equipment:
Storage tanks:
Pipes:
SCADA:
Dams:
Vehicles:
Other:
This template report was provided via the U.S. EPA's website on Federal Funding for Utilities - Water/Wastewater - in National Disasters (Fed FUNDS).
For further information, please visit
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