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Employee/Child Status
Additional Notes:
¨Child Care Center ¨Family Child Care Please check if any of the following apply to your program:
¨Other __________ ¨Private For-Profit
¨Public For-Profit ¨Tribal Program
DAMAGE ASSESSMENT TOOL
Name/Title of Person Completing Assessment
Brief Description of Disaster
Name of Program
Contact Person
Address
Director or Owner’s Name (If not contact person)
Phone
(landline and cell)
E-mail
Fax
#Enrolled/ Employed
# Present
# Injured
# Missing
# Released
Other
Staff
Children
Others
Type of Child Care Program
¨State Funded
¨Head Start/Early Head Start ¨Participate in Food Program
¨Private Non-Profit ¨Public Non-Profit ¨Accredited Program
¨Military Program
Licensing Capacity # of: __________________ Infants __________________ Toddlers __________________ Preschoolers __________________ School-age
Current # of children served post disaster: __________________ Infants __________________ Toddlers __________________ Preschoolers __________________ School-age
What is your assessment of the damage to your child care program?
¨Significant
Is street access available? Is your facility open?
¨Partial ¨Yes ¨Yes
¨Little or no evidence of damage ¨No
¨No
(_______A.M./P.M - _______A.M./P.M.)
If yes, what are the hours of operation?
Do you have the capacity to serve additional children? ¨Yes ¨No If yes, how many? __________
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