Emergency Management Organization

Enter information in the form below, or

Download the form. Fax, email or mail the completed form to Manitoba EMO.

Should you have any questions about the Community Impact Assessment, please contact us.

Items marked with asterisk (*) are required to submit the application.

Local Authority Information

Local Authority*:
Contact Person Name:
Position/Title:
Email:
Phone Number:
Alternate Contact Name:
Alternate Position/Title:
Alternate Email:
Alternate Phone Number:

Event

Type*:	(e.g. flood, heavy rains, wind storm, etc.)
Date of event *:	(yyyy/mm/dd)
Description:

Pre-emptive actions and activities (evacuations, diking, etc.)

Number of persons evacuated:
Evacuation start date:	(yyyy/mm/dd)
Evacuation end date:	(yyyy/mm/dd)
Pre-emptive actions (briefly describe actions taken to prevent or reduce damages):

Damages

Private Property (Private Sector)

	Minor Damage	Major Damage	Destroyed
Number of Homes:
Number of Farm Operations:
Number of Businesses:

Describe damages (e.g. basement and/or main floor flooding, wind and rain damages, fire losses, etc.):

Public Property (Public Sector)

Damage to Buildings (owned by local authority)

Building and damage description (include the building description (use) and description of damage to each building):

Municipal Infrastructure (Public Sector)

Number of bridges damaged:

Minor:
Major:
Destroyed:

Engineer Reports or contractor estimates:

Number of site(s) that require engineer reports or contractor estimates:

Total number of damaged sites:

Total number of all damaged sites (bridges, road washouts, culverts and drainage system damages):

Estimated damages:

Total estimated cost of all damaged sites:

$

Insurance:

Are any public sector damages covered by your insurance policy?

If yes, have you contacted your insurance provider?

Mitigation and Preparedness Program:

Do you plan to opt into the Mitigation and Preparedness Program?

Comments and Additional Information