Damage Assessment Checklist Form
Use this form to record damage details, assess severity, and note immediate follow-up actions for the affected property or asset.
Incident Details
Incident date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of damage
*
Brief description of what happened
*
Damage Assessment
Affected areas or items
*
Roof
Walls
Windows
Doors
Flooring
Electrical systems
Plumbing
Furniture
Equipment
Other
Overall damage severity
*
Minor
1
2
3
4
Severe
5
1 is Minor, 5 is Severe
Structural or functional impact assessment
*
Rows
Not impacted
Minor impact
Moderate impact
Severe impact
Structural integrity
1
2
3
4
Accessibility
5
6
7
8
Operational functionality
9
10
11
12
Safety
13
14
15
16
Condition and Follow-Up
Safe to use or access
*
Safe
Limited Use
Unsafe
Temporary repairs completed
*
Yes
No
Immediate action needed / next steps
Submit
Should be Empty: