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Flood Damage & Relief Assessment Form
Version 1.0 - Help us assess the damage and provide relief
Requesters
5
Rescuers
2
Reports
Flood Damage & Relief Assessment Form
Version 1.0 - Help us assess the damage and provide relief
A. Reporter Information
Reporter Name
*
Mobile Number
*
Reporter Type
*
Select...
Citizen
Volunteer
NGO
Government Official
Organization (if any)
Relationship to affected family
Select...
Self
Family
Village Representative
Volunteer
Other
B. Location Details
District
*
Select...
Baksa
Barpeta
Biswanath
Bongaigaon
Cachar
Charaideo
Chirang
Darrang
Dhemaji
Dhubri
Dibrugarh
Goalpara
Golaghat
Hailakandi
Hojai
Jorhat
Kamrup
Kamrup Metro
Karbi Anglong
Karimganj
Kokrajhar
Lakhimpur
Majuli
Morigaon
Nagaon
Nalbari
Sivasagar
Sonitpur
South Salmara
Tinsukia
Udalguri
West Karbi Anglong
Subdivision
Block
Gram Panchayat
Village
*
Landmark
GPS Location
Get Location
Click "Get Location" to auto-capture your current GPS coordinates
C. Household Information
Head of Family
*
Total Family Members
*
Children (<18 years)
Elderly (>60 years)
Pregnant/Lactating Women
Persons with Disabilities
Aadhaar (Optional)
Family Contact Number
D. Flood Status
Current Situation
*
Select...
Water Entered House
House Fully Submerged
Water Receded
Still Flooded
Water Level
Select...
Ankle
Knee
Waist
Chest
Roof
Flood Since
Evacuated?
Yes, evacuated
Currently Staying At
Select...
Home
Relief Camp
Relative
School
Other
E. Human Impact
Deaths
Missing Persons
Injured
Seriously Injured
Casualty Details
Gender
Male
Female
Other
Status
Deceased
Missing
Injured
Seriously Injured
Add Casualty
F. Property Damage
House Damage
*
Select...
No Damage
Minor Damage
Major Damage
Completely Destroyed
House Type
Select...
Kutcha
Semi-Pucca
Pucca
Estimated Damage (₹)
Household Assets Damaged
Bed
Furniture
TV
Refrigerator
Washing Machine
Fan
Motorcycle
Bicycle
Tractor
Agricultural Equipment
Mobile Phones
Documents Lost
School Books
Kitchen Utensils
Other
G. Livestock Loss
Animal
Alive
Missing
Dead
Cow
Buffalo
Goat
Pig
Poultry
Duck
Sheep
Other
H. Crop Damage
Crop Type
Area Affected
Acres
Bigha
Estimated Loss (%)
0%
Harvest Ready?
Yes, crop was ready for harvest
I. Business Loss
Business Type
Shop
Tea Stall
Small Business
Workshop
Others
Estimated Business Loss (₹)
J. Immediate Needs
Food
Dry Ration
Cooked Food
Baby Food
Water
Drinking Water
Water Purification Tablets
Shelter
Tarpaulin
Tent
Blankets
Mattress & Pillow
Clothes
Mosquito Net
Health
Medicines
Doctor
Ambulance
Sanitary Pads
ORS
Baby Care
Rescue
Boat
Evacuation
Animal Rescue
Others
K. Relief Already Received
Have you received any relief?
Relief Date
Organization
Items Received
Food
Water
Shelter
Clothes
Medicines
Cash
Other
Quantity
L. Accessibility
Road Accessible?
Boat Required?
Bridge Damaged?
Nearest Motorable Road
Electricity Available?
Mobile Network
Select...
Good
Weak
No Signal
M. Supporting Evidence
Upload Photos (Max 10)
You can upload up to 10 images
Upload Videos
Supported formats: MP4, MOV, AVI
Upload Audio Messages
Supported formats: MP3, WAV
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