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Disaster:
Date of Occurrence:
Duration:
2. Affected Area :
( Address; Village / City/ District / Region / Province)
Total Population:
4. Damages to livelihood
A. Men
B. Women
Did the affected families evacuate or do they remain in their respective homes?
A. Evacuation Centers (Specify name, location, distance from the place of origin)
B. In the absence of an evacuation center, please specify present location of the survivors and
amount
A. Medical
If yes, please state observed abnormal behaviors and how many are exhibiting such behavior.
Are there medical personnel who can help in the treatment of ill persons?
Water
Not potable
Food
2. Are these food stocks available locally? How long will these last?
Clothing
low many?
For Quantity
Children
Women
Men
(plastic Sheets}
Additional Information on the Area
Describe the physical feature of the area and the disaster threats / hazards (e.g. near the river
bank, low lying, fire/ toxic hazard from factory, narrow / congested streets, etc.} Place this at
DATE OF INTERVIEW
Respondent/S: