• 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

     to EMO or

     to reset

     

    --->