Corps of Engineers Civil Works Questionnaires Generic Clearance

PUBLIC DAMAGE SURVEY

(Personal Interview)

OMB 0710-0001

Expires: 30 September 2012

The public report burden for this information collection is estimated to average 40 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this data collection, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, and the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503, Attn.: Desk Officer for U.S. Army Corps of Engineers. Respondents should be aware that notwithstanding any other provision of law, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Please DO NOT RETURN your completed form to either of these offices.

PUBLIC DAMAGE SURVEY

1. Name of Governmental Entity: _______________________________

2. Agency: ______________________________________

3. Phone Number: ______________________________________

4. Dates of Flooding/

Coastal Storm: ______________________________________

5. Source(s) of Flooding: ______________________________________

6. In the table below list the damages that occurred to public property in your jurisdiction as a result of the (date) flood.

Type of Property	$ Damage	Primary Cause of Damage (inundation, wave, erosion, etc.)
Buildings
Equipment
Vehicles
Supplies
Streets, highways, roads
Water supply system plant and equipment distribution system
Sewage system plant and equipment distribution system
Drainage system
Bridges
Docks
Marinas
Boardwalks
Parks
Other
Total

7. Please list any other public cost that resulted from the flooding in your jurisdiction.

Type of Costs	$ Costs	Volunteer (unpaid hours)
Emergency operations and floodfighting
Police protection
Additional costs of water supply
Additional costs of sewage treatment
Additional costs of flood cleanup
Additional costs of trash collection and disposal
Replacement of business records
Repairs to levee, sand dunes, or other flood or coastal protection
Cleanup of hazard waste
Other costs
Total

8. Please describe any harmful public health and other environmental effects that flooding may have caused by inundation of landfills, sewage treatment plants, or other hazardous waste sites.

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