Hurricane Damage Assessment Survey

Hurricane Damage Assessment Survey
Please complete this survey to help document and assess damages caused by the recent hurricane. Your responses will assist in recovery and support efforts.
Property Owner/Resident Full Name
First NameLast Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Property Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Assessment
MonthDayYear
Date
Type of Property
Other
Areas of Property Affected and Severity
Rows Not Affected Minor Damage Moderate Damage Severe Damage
Roof
Windows/Doors
Exterior Walls
Interior Rooms
Utilities (Water/Electricity)
Garage/Outbuildings
Is the property currently safe to enter?
Utilities Status (Check all that apply)
Other (please specify)
Rate the overall impact of the hurricane on your property

1
2
3
4
5
6
7
8
9
10
1 is No Impact, 10 is Total Loss
Please upload photos of the damage (if available)
Cancelof
Additional Comments or Details
Signature of Property Owner/Resident
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Select theme:

Rows	Not Affected	Minor Damage	Moderate Damage	Severe Damage
Roof
Windows/Doors
Exterior Walls
Interior Rooms
Utilities (Water/Electricity)
Garage/Outbuildings