Disaster Response Field Assessment Form
Complete this form to rapidly assess disaster impact, urgent needs, and response priorities in the field.
Assessment Location (city/town, region, or GPS coordinates)
*
Date and time of assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of disaster
*
Earthquake
Flood
Hurricane/Cyclone
Landslide
Fire
Other
Estimated number of affected people
*
Please Select
Less than 100
100–499
500–999
1,000–4,999
5,000 or more
Severity of impact on the community
*
No impact
1
2
3
4
Catastrophic
5
1 is No impact, 5 is Catastrophic
Status of critical infrastructure and services
*
Rows
Fully Functional
Partially Functional
Non-Functional
Not Present
Electricity
1
2
3
4
Water Supply
5
6
7
8
Healthcare Facilities
9
10
11
12
Road Access
13
14
15
16
Telecommunications
17
18
19
20
Most urgent needs (select all that apply)
*
Medical assistance
Food and water
Shelter
Search and rescue
Sanitation/hygiene
Other
How accessible is the affected area?
*
Easily accessible
Accessible with difficulty
Not accessible
Gaps in available resources and capacity (Likert scale)
*
Rows
No gap
Minor gap
Moderate gap
Severe gap
Medical supplies
21
22
23
24
Food supplies
25
26
27
28
Clean water
29
30
31
32
Personnel
33
34
35
36
Transportation
37
38
39
40
Brief summary of key observations and immediate priorities
*
Submit Assessment
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