DISASTER EVALUATION CHECKLIST

School or Site Name*

Principal/Administrator*

Rate Overall Building Condition*

Natural Gas*

Minor LeakSerious LeakLoss of ServiceNo Issues

Power*

Loss of ServicePower Lines DownLive Wires ExposedNo Issues

Water*

Minor LeakSerious LeakLoss of ServiceNo Issues

Telephone*

Loss of Land Line ServiceLoss Of Cell ServiceLoss Of Radio ServiceNo Issues

Sewer*

Broken LinesBacking Up Into BuildingPuddling Outside BuildingNo Issues

Fire or Open Flames*

Classrooms/ Offices*

Modular Classrooms*

Hallways*

Building Entries*

Gymnasium/Lockers*

Restrooms*

Kitchen/Cafeteria*

Driveways and Parking Lots*

Faculty and/or Storage Rooms*

Windows, Doors & Ramps*

Auditorium*

Staff*

Students*

Visitors*

Please identify the name of any staff, student and/or visitor injured or missing. Please give as much detail as possible.

Identify injured staff members*

Identify injured students*

Identify injured visitors*

Police*

YesNoUnsure

Fire Department*

YesNoUnsure

D93 Maintenance*

YesNoUnsure

Will school need evacuation*

YesNoUnsure

Bussing Required*

YesNoUnsure

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Disaster Evaluation Checklist

Utilities Status

Facility Structure Status

Staff, Students & Visitors Status

Assistance Required