American Red Cross Form 5739

On-Site Detailed Damage Assessment Worksheet (Street Sheet)

DR #: :nbr:

DR Name: :name:

State: :state:

County: :cnty:

City/Community: :city:

Date: :date:

Street name: :street:

Geographical Reference: :georef:

House #

Apt / Unit #

Damage Classification

# floors in dwelling

Basement Y/N

Water Level inches

Water Level in basement

Electric Y/N

Own/Rent/ Seasonal

OR / 901

Destroyed

Major

Minor

Affected

Inaccessible

:hb[0]:

:ap[0]:

:des[0]:

:maj[0]:

:min[0]:

:aff[0]:

:acc[0]:

:flr[0]:

:bas[0]:

:wtr[0]:

:bwl[0]:

:ele[0]:

:occ[0]:

:or[0]:/:901[0]:

Description: :desc[0]:

Name: :nam[0]:

:hb[1]:

:ap[1]:

:des[1]:

:maj[1]:

:min[1]:

:aff[1]:

:acc[1]:

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:ele[1]:

:occ[1]:

:or[1]:/:901[1]:

Description: :desc[1]:

Name: :nam[1]:

:hb[2]:

:ap[2]:

:des[2]:

:maj[2]:

:min[2]:

:aff[2]:

:acc[2]:

:flr[2]:

:bas[2]:

:wtr[2]:

:bwl[2]:

:ele[2]:

:occ[2]:

:or[2]:/:901[2]:

Description: :desc[2]:

Name: :nam[2]:

:hb[3]:

:ap[3]:

:des[3]:

:maj[3]:

:min[3]:

:aff[3]:

:acc[3]:

:flr[3]:

:bas[3]:

:wtr[3]:

:bwl[3]:

:ele[3]:

:occ[3]:

:or[3]:/:901[3]:

Description: :desc[3]:

Name: :nam[3]:

:hb[4]:

:ap[4]:

:des[4]:

:maj[4]:

:min[4]:

:aff[4]:

:acc[4]:

:flr[4]:

:bas[4]:

:wtr[4]:

:bwl[4]:

:ele[4]:

:occ[4]:

:or[4]:/:901[4]:

Description: :desc[4]:

Name: :nam[4]:

:hb[5]:

:ap[5]:

:des[5]:

:maj[5]:

:min[5]:

:aff[5]:

:acc[5]:

:flr[5]:

:bas[5]:

:wtr[5]:

:bwl[5]:

:ele[5]:

:occ[5]:

:or[5]:/:901[5]:

Description: :desc[5]:

Name: :nam[5]:

:hb[6]:

:ap[6]:

:des[6]:

:maj[6]:

:min[6]:

:aff[6]:

:acc[6]:

:flr[6]:

:bas[6]:

:wtr[6]:

:bwl[6]:

:ele[6]:

:occ[6]:

:or[6]:/:901[6]:

Description: :desc[6]:

Name: :nam[6]:

:hb[7]:

:ap[7]:

:des[7]:

:maj[7]:

:min[7]:

:aff[7]:

:acc[7]:

:flr[7]:

:bas[7]:

:wtr[7]:

:bwl[7]:

:ele[7]:

:occ[7]:

:or[7]:/:901[7]:

Description: :desc[7]:

Name: :nam[7]:

:hb[8]:

:ap[8]:

:des[8]:

:maj[8]:

:min[8]:

:aff[8]:

:acc[8]:

:flr[8]:

:bas[8]:

:wtr[8]:

:bwl[8]:

:ele[8]:

:occ[8]:

:or[8]:/:901[8]:

Description: :desc[8]:

Name: :nam[8]:

:hb[9]:

:ap[9]:

:des[9]:

:maj[9]:

:min[9]:

:aff[9]:

:acc[9]:

:flr[9]:

:bas[9]:

:wtr[9]:

:bwl[9]:

:ele[9]:

:occ[9]:

:or[9]:/:901[9]:

Description: :desc[9]:

Name: :nam[9]:

Total single family:

:sf_des:

:sf_maj:

:sf_min:

:sf_aff:

:sf_ina:

Additional information: :addinf:

Total mobile home:

:mh_des:

:mh_maj:

:mh_min:

:mh_aff:

:mh_ina:

Total apartment:

:ap_des:

:ap_maj:

:ap_min:

:ap_aff:

:ap_ina:

Worker completing form: :worker:

Supervisor: :supervisor: