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Sample Water and Wastewater Damage Assessment Forms

Use these sample damage assessment, photolog, emergency repair, and mutual assistance forms to record damage to your utility. Provide blank forms to field crews assessing damage. Upon completion, you can use the forms to prioritize repairs.

These forms are not required for any of the funding programs. They are provided to help you document your damages sufficiently. This will further your probability of reimbursement or funding success.

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  • Water System Status Report (PDF)(1 pg, 144 K)
    This documents critical issues for water systems. Use this form to request mutual aid assistance from your local Water and Wastewater Agency Response Network (WARN).
  • Wastewater System Status Report (PDF)(1 pg, 144 K)
    Use this form to document critical wastewater system issues.
  • Suggested Questions for Water and Wastewater Utilities (PDF)(3 pp, 123 K)
    Use this form to provide detailed documentation of disaster and large-scale service interruption problems and damage.
  • Natural Disaster Incident Report Form (PDF)(4 pp, 529 K)
    Use this form to document operational status of your utility.
  • Photolog (PDF)(1 pg, 102 K)
    Use this resource to organize your photographs of your utility's damaged assets and equipment. Provide your field crews with a camera or camcorder to document damaged equipment and facilities. Crews should reference the photos in assessment or repair forms.
  • Emergency Repair Form (PDF)(1 pg, 90 K)
    Use this form to document emergency work if your utility does not have a work order system in place. Each repair crew should use the utility's work order management system, if appropriate, to document any work.