Damage Assessment Form
This form is for citizens of Johnson County to complete regarding property damaged suffered during a severe weather event. Information gathered will be reviewed by Johnson County Emergency Management; and if applicable forwarded to partnering agencies such as the National Weather Service and/or State Emergency Management Agency.
Incident Information
This section will include information regarding the specific incident causing the damage.
What incident was the damage a result of? *
Date of Damage
MM
/
DD
/
YYYY
Time of Damage
Time
:
Property Information
This section will include information regarding the property damage.
Property Type *
Property Address *
Example: 123 Main Street
Your answer
Property City *
Property Owner *
First Name | Last Name
Your answer
Contact Number *
Property Owner Contact Number
Your answer
Contact Email *
Property Owner Contact Email Address
Your answer
Damage Information
This section will include information regarding the damage sustained.
Cause of Damage *
Required
Vegetative Damage *
Required
Miscellaneous Damage *
Required
Did your property have any structural damage impacts? *
Required
Structural Level of Damage *
Estimated Damage Amount *
Estimated Value of Structure
Your answer
Comments
Describe Damage (Specifically any Structural Damage)
Your answer
Preparatory Information
This section will include information regarding the person who completed this form.
Name of Person Preparing Form *
First Name | Last Name
Your answer
Contact Number *
Your answer
Contact Email Address *
Your answer
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This form was created inside of University of Central Missouri.