OERS INCIDENT #: ________
OREGON EMERGENCY MANAGEMENT
Initial Damage Assessment (IDA) Summary Report Form

JURISDICTION: 
NAME OF REPORTING OFFICIAL: 
EMAIL: 
TITLE: 
TELEPHONE:
FAX:
PAGER: 
DATE AND TIME OF THIS REPORT:
DATE AND TIME OF START OF THE EVENT: 
EOC ACTIVATED?:
DATE:
TIME: 
EOC CLOSED?:
DATE:
TIME: 
LOCAL EMERGENCY DECLARED?:
DATE:
TIME: 
TYPE OF EMERGENCY:
DESCRIBE THE GEOGRAPHIC BOUNDARIES (and attach a map if possible) 

DEATHS:
INJURIES:
POP. STILL AT RISK:
CURRENT SITUATION AND EXISTING CONDITIONS: 

IMPACTS OF THE DISASTER TO THE JURISDICTION:

IDENTIFY AND DESCRIBE CONDITIONS THAT CONSTITUTE A HEALTH OR SAFETY 
HAZARD TO THE GENERAL PUBLIC: 

DESCRIBE THE POPULATION ADVERSELY AFFECTED DIRECTLY OR INDIRECTLY BY THE 
LOSS OF PUBLIC FACILITIES OR DAMAGES: 

WHAT ECONOMIC ACTIVITIES ARE ADVERSELY AFFECTED BY THE LOSS OF PUBLIC 
FACILITIES OR DAMAGES?: 

ACTIONS TAKEN / RESOURCES COMMITTED: 

ASSISTANCE REQUESTED: 

___________________________________________________

IDA Summary Report Form
Page 2
HOUSING COSTS & LOSS #     $$s       COMMENTS
Destroyed:          _____ $_________ ____________________
Major damage:       _____ $_________ ____________________
Minor damage:       _____ $_________ ____________________
Affected habitable: _____ $_________ ____________________
Second homes:       _____ $_________ ____________________
Personal property 
(not included above): _____ $_________ ____________________
Dollar loss estimate for housing: $_________

BUSINESS COSTS & LOSS #   $$s       COMMENTS
Destroyed:         _____ $_________ ____________________
Major damage:      _____ $_________ ____________________
Minor damage:      _____ $_________ ____________________
Business interrupted: _____ $_________ ___________________
Dollar loss estimate for business: $_________

PRIVATE NONPROFIT COSTS & LOSS # $$s COMMENTS
Destroyed:        _____ $_________ ____________________
Major damage:     _____ $_________ ____________________
Minor damage:     _____ $_________ ____________________
Service interrupted: _____ $_________ ___________________
Dollar loss estimate for PNPs: $_________

AGRICULTURE COSTS & LOSS # $$s COMMENTS
Crop loss (acres / $$s): _____ $_________ ____________________
Equipment lost/damaged:  _____ $_________ ____________________
Livestock lost:          _____ $_________ ____________________
Out-buildings damaged:   _____ $_________ ____________________
Dollar loss estimate for agriculture: $_________

___________________________________________________

IDA Summary Report Form
Page 3
INFRASTRUCTURE
CITY(IES) COSTS & LOSS # $$s COMMENTS
A. Debris clearance:     _____ $_________ ____________________
B. Protective measures:  _____ $_________ ____________________
C. Transportation system damage:
Federal Aid System (FAS) _____ $_________ ____________________
non-Federal Aid System   _____ $_________ ____________________
D. Water control facilities: _____ $_________ ____________________
E. Public buildings / equipment:
insured                  _____ $_________ ____________________
uninsured                _____ $_________ ____________________
F. Public utility systems: _____ $_________ ____________________
G. Parks and other:      _____ $_________ ____________________
Dollar loss estimate for the city(ies): $_________

SPECIAL DIST. COSTS & LOSS # $$s COMMENTS
A. Debris clearance:     _____ $_________ ____________________
B. Protective measures:  _____ $_________ ____________________
C. Transportation system damage:
Federal Aid System (FAS) _____ $_________ ____________________
non-Federal Aid System   _____ $_________ ____________________
D. Water control facilities: _____ $_________ ____________________
E. Public buildings / equipment:
insured                  _____ $_________ ____________________
uninsured                _____ $_________ ____________________
F. Public utility systems: _____ $_________ ____________________
G. Parks and other:      _____ $_________ ____________________
Dollar loss estimate for special district(s): $_________

___________________________________________________

IDA Summary Report Form
Page 4
STATE FACILITIES COSTS & LOSS # $$s COMMENTS
A. Debris clearance:     _____ $_________ ____________________
B. Protective measures:  _____ $_________ ____________________
C. Transportation system damage:
Federal Aid System (FAS) _____ $_________ ____________________
non-Federal Aid System   _____ $_________ ____________________
D. Water control facilities: _____ $_________ ____________________
E. Public buildings / equipment:
insured                  _____ $_________ ____________________
uninsured                _____ $_________ ____________________
F. Public utility systems: _____ $_________ ____________________
G. Parks and other:      _____ $_________ ____________________
Dollar loss estimate for state facilities: $_________


COUNTY COSTS & LOSS # $$s COMMENTS
A. Debris clearance:     _____ $_________ ____________________
B. Protective measures:  _____ $_________ ____________________
C. Transportation system damage:
Federal Aid System (FAS) _____ $_________ ____________________
non-Federal Aid System   _____ $_________ ____________________
D. Water control facilities: _____ $_________ ____________________
E. Public buildings / equipment:
insured                  _____ $_________ ____________________
uninsured                _____ $_________ ____________________
F. Public utility systems: _____ $_________ ____________________
G. Parks and other:      _____ $_________ ____________________
Dollar loss estimate for county facilities: $_________
___________________________________________________

IDA Summary Report Form
Page 5
TOTALS - ALL GOVERNMENTS # $$s COMMENTS
A. Debris clearance:     _____ $_________ ____________________
B. Protective measures:  _____ $_________ ____________________
C. Transportation system damage:
Federal Aid System (FAS) _____ $_________ ____________________
non-Federal Aid System   _____ $_________ ____________________
D. Water control facilities: _____ $_________ ____________________
E. Public buildings / equipment:
insured                  _____ $_________ ____________________
uninsured                _____ $_________ ____________________
F. Public utility systems: _____ $_________ ____________________
G. Parks and other:      _____ $_________ ____________________

Grand total estimate for all
infrastructure in the jurisdiction: $_________

Estimated Total Dollar Cost to the Jurisdiction: $_________
(Grand total of housing, business, private non-
profit, agriculture, and infrastructure)

SIGNATURE OF SUBMITTING OFFICIAL:___________________________
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