• Surveyor
  • Date
  • Time

Location

  • Floor Number
  • Office/Unit

Type of Damage [check all that apply]

  • Debris
  • Mold/Mildew
  • Mud
  • Water, High (dripping wet)
  • Water, Low (damp)
  • Smoke
  • Fire
  • Sewage
  • Insects
  • Rodent
  • Other

Type of Media [check all that apply]

  • Paper
  • Books
  • Photographs
  • Slides
  • Videos/Audio Tapes
  • Microfilm/Microfiche
  • Oversized Materials [maps, posters]
  • Glossy Paper [magazine stock]
  • Computer Disks
  • CD-ROMs
  • Other

Additional Description of Damaged Materials [check all that apply]

  • Vital Records [time critical, needed for continued function of Office/Unit]
    • Type(s) of records/file names
    • Volume in feet:
    • Dates of records:
  • Program Specific Records [ARs, permits, grants, contracts, enforcement records, etc.]
    • Type(s) of records/file names
    • Volume in feet:
    • Dates of records:
  • Confidential Records
    • Type(s) of records/file names
    • Volume in feet:
    • Dates of records:
  • "For official use only" Records
    • Type(s) of records/file names
    • Volume in feet:
    • Dates of records:
  • Housekeeping Records [time cards, leave slips, travel paperwork, etc..]
    • Type(s) of records/file names
    • Volume in feet:
    • Dates of records:
  • Non-Record Materials [technical reference, personal papers, etc.]
    • Type(s) of records/file names
    • Volume in feet:
    • Dates of records:

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