COUNTY STATEMENT OF IMPACT

County Name: Event:
The impact statement should not dwell on financial losses only, but the hardships and challenges encountered by the community particularly casualties, stresses on special needs populations, tasking of Emergency Responders, loss of vital services and utilities or any other clear and compelling justification for Federal assistance to help in recovering from the effects of the event.
When completed send to your PEMA Area Office: ; ; or
It is imperative that your PEMA Area Office receives this form immediately upon completion.
Event Description and Ongoing Dangers to Public Safety:
Narrative: Describe the nature of the event, specific trends in your county, and description of dangers to public safety: Example – “Flooding has contaminated public drinking water, high winds/debris have left numerous dwellings structurally unsound”
Event Casualties:
DEATHS- #Reported: #Confirmed: Confirmed By:
INJURIES- #Reported: #Confirmed: Confirmed By:
Narrative: Describe any concentrated locations or common causes of mass casualties, impact to Emergency Responders – including readiness/ability to respond to additional events, and event information ongoing/ended/remaining dangers to life and safety
Special Needs Populations and Specific Impact/Requirement:
Narrative: Describe any special needs populations adversely affected by event and specific unmet needs they may require
Housing/Sheltering:
# Displaced Persons: #Shelters Established: #Required:
Established Shelters and Addresses
Are Non-Impacted Rental/Housing resources sufficient to meet displaced persons’ needs? YES____NO____
Loss of Vital Utilities:
Narrative: Describe loss of vital utilities such as electricity/water/gas, number of customers without, estimated time of restoration, and special considerations – electrical support of medical equipment, climate control in extreme hot/cold weather
Loss of Vital Infrastructure:
Narrative: Describe infrastructure damage and impact to community operations – Example:” loss of a bridge across XX Creek:, loss of bridge causes 45 minute detour and delay in EMS response from the only hospital
Actions by County Officials and Emergency Responders:
Narrative: Describe actions taken by County Officials and Emergency Responders. Include effectiveness in controlling current situation, ability of responders to respond to additional events, major limitations, and effectiveness of existing emergency action plan
Actions by Volunteer Organizations:
Narrative: Describe actions by Volunteer organizations – include number of volunteers and rough estimate of money expended if known, describe level of activity in relation to needs; are there significant unmet needs or needs beyond the scope of the volunteer agencies
Damage and Surveys:
Damage Locations:
Narrative: Describe location of damage, amount of area surveyed
Predominant Types of Structures Surveyed:
Construction (Wood/Brick/Frame/Mfd), Configuration (Multi-Story, Basements)
Damage to Manufactured Homes
Inaccessible Areas:
Describe remote or major inaccessible areas and cause of inaccessibility
Economic Impact
#Businesses Impacted
Community’s Major Employers
List Major Employers, number of employees each, and damage/impact suffered – particular attention to estimated time before workers will return to work
Agricultural Impact
Include loss of livestock /crops and estimated population percentage engaged in agricultural employment
Other Factors Impacting Tax Base:
Vacation/Tourist Properties damaged, permanent exodus from disaster area, loss of commercial areas, loss of production base
Authorized Individual Signature:

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