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WINDSHIELD SURVEY FORM Municipality EMC Name Private Property Date / Time For definitions of Reporting Categories see back of form Destroyed Major Minor Affected Inaccessible Businesses Mobile Home Multi-Family Single Family Public Bridges Culverts Fire / EMS Facility Hospital Damaged Directions 1 If damage has been sustained by your municipality document the number of property types impacted in the appropriate column. 2 DO NOT use this form to document monetary estimates of damage use Nursing Home Other Park Power Supply Public Bldg City Hall Etc. Roads Sanitary Sewer School 3 If debris removal or emergency protective measures are in place be sure to complete the appropriate form and circle Yes to the questions listed at the bottom of this form. 4 Complete this form and return to Berks DES within 24 hours after the passing of the event. Berks County Department of Emergency Services Phone 610 374-4800 Sewer Treatment Fax 610 374-8865 Storm Sewer Water Control Facility berksdes countyofberks. com Water Supply Water Treatment Are debris removal activities occurring in the municipality Yes / No Are emergency protective measures in place in the municipality If YES is checked for either or both complete Protective Action/Debris Removal Form Non-Flood Damage Category Definitions - Some shingles and/or siding missing Ingress / Egress to residence may be hampered Dwelling is livable without repairs IE Stone driveway is washed away due to heavy rains - Property is usable however repairs may be required - Critical components of the facility are inoperable pumps electric etc* Property is no longer there Property is structurally unsafe All major structural systems are damaged and habitation is not possible IE Structure has partially collapsed - IE Bridge out leading to property - Large portions of roof missing - Structure or property cannot be used until repairs are made - IE Roof blown off due to high winds Property is damaged but usable Numerous broken windows Minor structural damage IE Roofing shingles blown off due to high winds Flood Damage Category Definitions AFFECTED MINOR MAJOR DESTROYED HOUSE Crawl Space X Basement Less than 1 1 or more Extensive found. damage First Floor 2 or less Up to 2 but not affecting electric outlets Physically Slab House 6 or more into mobile home Second Floor MOBILE HOME No water into Belly From Belly Board to Board 6 on floor Quick Guide to Determining Damage Category Is the structure usable as it is YES Does it need temporary repairs to be lived in now NO Can it be made usuable again with extensive repairs Yes - Minor Yes - Major Revision 3 120808. Berks County Department of Emergency Services Phone 610 374-4800 Sewer Treatment Fax 610 374-8865 Storm Sewer Water Control Facility berksdes countyofberks. com Water Supply Water Treatment Are debris removal activities occurring in the municipality Yes / No Are emergency protective measures in place in the municipality If YES is checked for either or both complete Protective Action/Debris Removal Form Non-Flood Damage Category Definitions - Some shingles and/or siding missing Ingress / Egress to residence may be hampered Dwelling is livable without repairs IE Stone driveway is washed away due to heavy rains - Property is usable however repairs may be required - Critical components of the facility are inoperable pumps electric etc* Property is no longer there Property is structurally unsafe All major structural systems are damaged and habitation is not possible IE Structure has partially collapsed - IE Bridge out leading to property - Large portions of roof missing - Structure or property cannot be used until repairs are made - IE Roof blown off due to high winds Property is damaged but usable Numerous broken windows Minor structural damage IE Roofing shingles blown off due to high winds Flood Damage Category Definitions AFFECTED MINOR MAJOR DESTROYED HOUSE Crawl Space X Basement Less than 1 1 or more Extensive found.

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