Information
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Conducted on
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Prepared by
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Location
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General Information
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Type of area
- surburban
- rural
- industrial
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Nature of event
- wind
- flood
- storm surge
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Contact Name and Number
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Is power available
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Was power disrupted?
- <2hrs
- 2-4hrs
- >4hrs
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Is property easily accessible by road?
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Estimated number of people at the property
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Drinking Water
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Is the distribution system working (e.g. Tap water)?
- yes
- no
- N/A
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Does the water appear to be contaminated (e.g. Dirty), or at risk of microbial or chemical contamination?
- yes
- no
- N/A
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Is there an alternative water supply available?
- yes
- no
- N/A
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Sewage, Waste and Asbestos
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Is town sewage available?
- yes
- no
- N/A
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Is there an on-site sewerage system available?
- yes
- no
- N/A
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Is there a public health hazard from sewage or liquid waste?
- yes
- no
- N/A
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Do people have access to functioning toilets?
- yes
- no
- N/A
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Are additional toilets required
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Is waste posing a public health risk
- yes
- no
- N/A
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If yes what is the time frame of the public health risk?
- short term
- medium term
- long term
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Does any if the waste look like it contains asbestos?
- yes
- no
- N/A
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Is it bonded or friable?
- bonded
- friable
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Will machinery create a public health risk (e.g. lawn mowers, vehicles, heavy equipment)?
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Should asbestos handling information be disseminated?
- yes
- no
- N/A
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Contact email:
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Is a mass clean up required for all waste?
- yes
- no
- N/A
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Comment
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Add media
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Food Safety
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Premises Type:
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Is the premises operating?
- yes
- no
- N/A
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Has there been damage to the premises
- yes
- no
- N/A
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Is suitable refrigeration available?
- yes
- no
- N/A
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Did you seize any food?
- yes
- no
- N/A
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Details:
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Other specific comments (e.g cleaning required)
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Other
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Personal Hygiene
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Are there adequate facilities for personal washing, cleaning and bathing?
- yes
- no
- N/A
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Is there a need for personal hygiene products to be supplied?
- yes
- no
- N/A
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Shelter
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Is the premises overcrowded?
- yes
- no
- N/A
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Are residents camping?
- yes
- no
- N/A
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Vector, vermin and animal control
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Are there exposed piles of refuse, dead animals, or putrescible material?
- yes
- no
- N/A
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Are there potential mosquito breeding sites?
- yes
- no
- N/A
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Are flies, Mosquitos or other insect pests in numbers to cause concern?
- yes
- no
- N/A
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Do residents require insect repalent?
- yes
- no
- N/A
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Are rodent populations visibly present?
- yes
- no
- N/A
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Are roaming animals an issue?
- yes
- no
- N/A
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Detail:
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Chemical Hazards
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Are there any stored chemicals that may pose a public health risk?
- yes
- no
- N/A
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Have any chemicals been released?
- yes
- no
- N/A
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Add media
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Priority Areas
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Drinking Water
- low
- medium
- high
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Food Safety
- low
- medium
- high
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Personnel Hygiene
- low
- medium
- high
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Sewage
- low
- medium
- high
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Solid waste management
- low
- medium
- high
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Asbestos
- low
- medium
- high
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Shelter
- low
- medium
- high
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Vector and vermin control
- low
- medium
- high
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Chemical Hazards
- low
- medium
- high
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All other comments
