Flood and Coastal Storm Damage Surveys

OMB CONTROL NUMBER: 0710-0017

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0710-0017, is estimated to average 30 minutes per survey, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

NONRESIDENTIAL

Background Information

1. Briefly describe the major purpose of this business facility? ________________

______________________________________________________________________

2. What is the total number of buildings on site _____ Buildings

3. Number of years business has been at this location _____ Years

4. Please indicate the number of full time, part time, and total employees.

_______ Full Time ________ Part Time ________Total Employees

5. How many shifts are there in your daily operation?

______ Shifts per day

6. While at this location, approximately how many times has this facility experienced flood damage, including the flooding from ­­­­­­­the (date) floods?

_________ Times

7. Briefly describe any permanent flood mitigation measures that have been implemented to reduce potential flood damage.

8. How many days, if any, was this business closed due to the (date) flood?

__________ DAYS CLOSED

8a. Did your business set up temporary quarters at another location because of the (date) floods? (CIRCLE)

1. NO

2. YES

8b. How much additional money did the flood cost your business in increased operational expenses, such as temporary quarters, additional transportation, communications, or storage expenses?

$____________ Total Additional Dollars

8c. Please describe additional costs. ___________________________________________________________________

___________________________________________________________________

Individual Building Information

(Questions 9-21 are to be answered for your primary building only. If there are multiple buildings at the facility, a supplemental sheet is provided that asks for similar information.)

9. Brief description of function of the primary building and its contents:

10. Prior to the (date) floods, what was the value of all equipment

physically attached or anchored to this building, not including

the building itself? $________

11. Prior to the (date) floods, what was the value of all other

equipment, furniture, supplies, raw materials, and inventory

generally stored in this building? $________

12. Prior to the (date) floods, what was the value of all

vehicles generally stored at this building? $________

13. Prior to the (date) flooding, what was the value of all

other equipment, supplies, and inventory stored outside of,

but in the immediate vicinity of this building? $________

14. Excluding any basement or attic how many stories does this building have?

_______________ STORIES

15. What is the average story height in this building?

_______________ FEET

16. What year was this building constructed? ___________________

17. What is the shape of this building? (Circle one answer.)

1. Square

2. Rectangular

3. L-shaped

4. U-shaped

5. Very Irregular

18. What is the size of your building in square feet? (If respondent is unsure, ask for the dimensions and calculate.)

___________ SQUARE FEET

19. Indicate what type of heating and cooling system is used in your building?

Heating Only:

1. Forced Air 6. Ceiling, Radiant Electric

2. Gravity Furnace 7. Baseboard, Electric

3. Floor Furnace 8. Baseboard, Hot Water

4. Wall Furnace 9. Radiators, Hot Water

(No Heat Ducts) 10. Radiators, Steam

5. Floor, Radiant Hot Water

Heating and Cooling:

11. Warmed and Cooled Air

12. Heat Pump System

Cooling Only:

13. Evaporative Water Cooler (Single or Short Ducts)

14. Refrigerated, with Condenser and Ducts

20. Does this building have a basement? (CIRCLE)

0. NO

1. YES

20a. If yes, please indicate the total basement area, and the area in square feet or dimensions of the area that is finished and unfinished? (If respondent is unsure, ask for the dimensions and calculate.)

Total Area: ________________ Square Feet

Finished Area: _____________ Square Feet

Unfinished Area: ___________ Square Feet

21. Please indicate the primary construction material for the building frame.

___Block/Brick ___Steel ___Wood ___Metal

(Check appropriate block)

22. Relative to the 1^st floor elevation of the building, what is the current value of the contents and where are they located vertically? (up through 1^st floor only)

Height (ft)	Equipment ($)	Furniture ($)	Inventory/products ($)
0.0 ft
1.0 ft
3.0 ft
6.0 ft
8.0 ft
Total

Notes to interviewer:

• Shaded areas are for buildings with a subterranean level only. Please fill in appropriate values for the depth (e.g., -1.0 ft, -3.0 ft, -6.0 ft). Leave shaded areas blank if no subterranean level exists.

• The values in the columns should be a cumulative total, starting from the lowest level of the structure.

Physical Damage and Other Costs

23. How high in feet and inches did the water from ______ (year) flood reach on the inside of this building relative to the first floor of the building?

______ FEET; _______ INCHES (ABOVE, BELOW) First Floor Level

[CIRCLE]

24. Please estimate the damages to your business from past flooding events. Please give a single set of combined damages for all floors in all buildings.

Date of the flooding event:	__________	Date of the flooding event:	__________
Contents damage estimate ($):	$_________	Contents damage estimate ($):	$_________
Structure damage estimate ($):	$_________	Structure damage estimate ($):	$_________
Number of lost business days:	______Days	Number of lost business days:	______Days
Amount of lost net income ($):	$_________	Amount of lost net income ($):	$_________
Cost of cleanup ($):	$_________	Cost of cleanup ($):	$_________

25. Please indicate the replacement value and damage or costs that you attribute to each of the following items.

		Replacement Value	Actual Damage or Cost
Damage to Transportation
Roads, bridges, streets, walks, parking		$_________	$_____________________
Rail beds and tracks		$_________	$_____________________
Rerouting trains, trucks, cars, & buses		$_________	$_____________________
Docks and loading facilities		$_________	$_____________________
Damage to Buildings
Foundation and supports		$_________	$_____________________
Floors (mark one) ___Steel ___Concrete ___Wood		$_________	$_____________________
Floor covering (mark one) ___Ceramic ___Linoleum ___Carpet		$_________	$_____________________
Exterior walls and insulation (mark one) ___Metal ___Wood ___Block/brick		$_________	$_____________________
Windows		$_________	$_____________________
Interior walls and ceilings		$_________	$_____________________
Doors and moldings		$_________	$_____________________
Damage to Building Utilities Indicate location: B=Basement, G=Ground floor, I=Intermediate floors, R=Roof	Replacement Value		(year)Flood Actual Damage or Cost
Sewer systems ___Storm ___Industrial ___Sanitary ___B ___G ____I ___R	$_________		$_____________________
Water supply systems ___Treatment ___Pipes ___B ___G ____I ___R	$_________		$_____________________
Water systems ___Hot water ___Softening ___B ___G ____I ___R	$_________		$_____________________
Communications systems ___B ___G ____I ___R	$_________		$_____________________
Electric power transformers ___Pole ___Ground	$_________		$_____________________
Electrical service entrance and meters ___B ___G ____I ___R	$_________		$_____________________
Engines/generators/alternators ___B ___G ____I ___R	$_________		$_____________________
Other Electrical control panels and circuit breakers ___B ___G ____I ___R	$_________		$_____________________
Wiring switches, outlets, lighting ___B ___G ____I ___R	$_________		$_____________________
Fuel supply ___Oil tanks ___Gas pipes/meters ___B ___G ____I ___R	$_________		$_____________________
Heating ___Oil ___Gas ___Elect. ___Air ___Water ___B ___G ____I ___R	$_________		$_____________________
Air conditioning ___Gas ___Electric ___Cool ___Purify ___Dehumidify ___B ___G ____I ___R	$_________		$_____________________
Damage to Equipment, Appliances, and Furniture
___Conveyors ___Elevators ___Escalators	$_________		$_____________________
Foundry furnaces and welding equipment	$_________		$_____________________
Machine tools and patterns	$_________		$_____________________
Other motors and engines	$_________		$_____________________
Compressors	$_________		$_____________________
Built-in refrigeration units	$_________		$_____________________
Hand and paint tools	$_________		$_____________________
Other equipment	$_________		$_____________________
Display cases, counters, and bins	$_________		$_____________________
Appliances ___Oven ___Refrigerators ___Other _____________________	$_________		$_____________________
Vehicles kept at this location	$_________		$_____________________
Damage to:
Parts/raw materials	$_________		$_____________________
Partly assembled/processed product	$_________		$_____________________
Inventory	$_________		$_____________________
General Costs
Fighting the Flood			$_____________________
Evacuation ___Owner ___Tenant			$_____________________
Number of employees out of work			____________ Unemployed
Value of lost wages			$_____________________
Removal of debris and damaged items			$_____________________
Disinfecting, other cleaning and rehabilitation			$_____________________
Replacement of records			$_____________________
Loss of gross income due to interruption of business			$_____________________
Loss of net income due to interruption of business			$_____________________
Increased alternative operating costs			$_____________________

26. Please indicate the approximate dollar value of damage from the (date) floods to the following categories:

Structure Damage = Damage to any building components, including foundation, walls, floors, doors, windows, roof, electrical system, heating and cooling systems, plumbing, attached carpeting, attached shelves and cabinets, and built-in equipment and appliances.

Content Damage = Damage to unattached equipment, supplies, raw materials, and inventory.

Vehicles and Outside Property Damage = Damage to vehicles parked on premises; damage to inventory, materials, and equipment kept outside; and damage to signs, landscaping, and parking areas.

Preventive Costs = Costs of moving contents prior to and after flooding to avoid damage, costs of flood fighting.

Clean Up Costs = Costs of labor and materials to clean up interior and outside of building.

Business Record Replacement Costs = The financial costs and unpaid hours for reconstructing business records that were damaged by the flood.

TYPE OF DAMAGE	AMOUNT OF COST OR DAMAGE
STRUCTURE DAMAGE	$_________________________________
CONTENT DAMAGE	$_________________________________
VEHICLE DAMAGE	$_________________________________
PREVENTIVE COSTS	$_________________________________
CLEANUP COST	$_________________________________
LANDSCAPING AND OUTSIDE PROPERTY	$_________________________________
UNPAID HOURS OF TIME FOR CLEAN AND REPAIR	____________________ UNPAID HOURS
BUSINESS RECORD REPLACEMENT COSTS	$_________________________________

27. How long did the water remain in this building?

_____________ DAYS _____________ HOURS

Damage Susceptibility

28. At what elevation, relative to the 1^st floor of the building, does flood damage to contents begin? (+ or – ; will only be negative if there is a subterranean level) ____________ feet

29. Please estimate damage to contents corresponding with water depths above/below the building’s 1^st floor elevation. (Express damage in either $ or % of total value.)

Flood Depth	Equipment			Furniture				Inventory/products
	Low	Most Likely	High		Low	Most Likely	High	Low	Most Likely	High
-6.0 ft
-3.0 ft
-1.0 ft
0.0 ft
0.5 ft
1.0 ft
3.0 ft
6.0 ft

Notes to interviewer:

• Shaded areas are for buildings with a subterranean level only. Please fill in appropriate values for the depth (e.g., -1.0 ft, -3.0 ft, -6.0 ft). Leave shaded areas blank if no subterranean level exists.

• The values in the columns should be a cumulative total, starting from the lowest level of the structure.

• Other Information

30. Is there a seasonal variation in the value of inventory in this building? Yes No

If yes, what is the average total value of your inventory during the following time periods:

January – March $ April – June $

July – September $ October – December $

31. Other than the principal structures, are there any other valuable items on your property that flood waters could damage, such as not readily movable (landscaping, electrical equipment, pipes, trailers on blocks, etc.)?

Type	Current Value ($)	Height Above Ground (ft.)

- Movable (cars, trucks, trailers, etc.)

Type	Current Value ($)

Flood Warning and Response

32. Just before (date) floods, how did you first become aware that flooding might reach your business? (CIRCLE ONE ANSWER)

1. E-MAIL

2. TEXT MESSAGE

3. SOCIAL NETWORKING WEBSITE (FACEBOOK, TWITTER, SNAPCHAT, etc.)

4. TV

5. RADIO

6. TELEPHONE BY A PUBLIC OR EMERGENCY WORKER

7. TELEPHONE BY OTHER

8. FACE TO FACE BY PUBLIC OR EMERGENCY WORKER

9. FACE TO FACE BY OTHER

10. LOUDSPEAKER

11. SIREN

12. C.B., HAM RADIO or POLICE SCANNER

13. NEWSPAPER

14. OBSERVING THE CREEK OR RIVER WATER LEVELS

15. OTHER ______________________________________

32a. How many hours were there between the time you became aware that flooding might reach your business until the water actually reached your business property?

______ HOURS

33. What actions, if any, did you take to safeguard your business property

immediately prior to flooding and what were the dollar damages prevented by each action?

(PLEASE CIRCLE YES OR NO FOR EACH ACTION LISTED AND INDICATE THE DOLLARS DAMAGE PREVENTED FOR EACH ACTION.)

Damage Preventive Action	Took Preventive Action (CIRCLE)	Dollar Damage Prevented $____ or Circle DK for Don’t Know
1. Moved contents to higher ground	Yes No	$_________ DK
2. Elevated contents to a higher spot in the building	Yes No	$_________ DK
3. Shut off electrical equipment	Yes No	$_________ DK
4. Sandbagged the outside of the building	Yes No	$_________ DK
5. Used another type of temporary barrier	Yes No	$_________ DK
6. Moved vehicles to higher ground	Yes No	$_________ DK
7. Other action: _____________________________	Yes No	$_________ DK
8. None	Yes No	$_________ DK

34. Emergency Measures/Plans:

34a. What emergency measures/plans, if any, would you take to reduce damage if you were forewarned of eminent flooding?

34b. What is your estimated cost to implement these emergency measures?

$

34c. How much time in man hours is required to implement these emergency measures?

MAN HOURS