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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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