REPORT FORM

HEADER: DE (CALLSIGN) NR (Message Nmbr)

(PRECEDENCE) (P=ACTUAL R=EXERCISE) (DATE) (TIME) Z (MONTH) (YEAR)

(Members Name/Callsign/State)

TO: DOMS EMAIL: doms@fema.gov (or) FAX: 1-703-697-3147

INFO: AGA3C

(STATE EOC)

BT

SUBJECT: ACTUAL EVENT/EEI (or) MARS EXERCISE (circle one)

(Use applicable Identifier or Plain Language if not on Identifier List)

A. AREA IMPACTED BY THE INCIDENT: (Specify Town, City, County or State-wide area)

B. STATUS OF EMERGENCY MEDICAL FACILITIES: (Operational, Damaged, Destroyed, or Field Facilities available)

C. STATUS OF LOCAL TRANSPORTATION FACILITIES: (Indicate which roads, bridges, local airports, RAILROADS are affected and status - open, restricted, closed, damaged, destroyed. Provide enough information to disaster relief officials to aid in deciding how to get assistance to the affected area)

D. EXACT LOCATION AND CHARACTERISTICS OF DAMAGE: (General description of damage or impact on Major structures such as Government buildings, schools, residences, commercial properties, public facilities, Fire Stations, Etc. Include locations of shelters if applicable.)

E. STATUS OF AREA UTILITIES: (Gas, Water, Commercial Power, Sanitation Systems, - Operational, Damaged, Destroyed, needed)

F. STATUS OF COMMERCIAL COMMUNICATIONS FACILITIES: (Telephone, Radio, TV, Cellular Phone - Operational, Damaged, Unavailable)

G. SOURCE OF INFORMATION: (Indicate Source of information if different from DATE TIME GROUP of the message. Include MARS Callsign, name of official and agency, radio/TV station Callsign or network as applicable)

H. REMARKS: Include comments about expected changes in status of any of the above items such as power companies expect power to be out for (specify estimated time). If applicable, include expected time of next report.

2. ACTUAL EVENT/EEI (or) MARS EXERCISE (circle one) Same as Subject Line