Add an agency or group name: 

PRECEDENCE: Z/ FlashO/ ImmediateP/ PriorityR/ Routine

DATE/TIME:     TASK: # 

FROM: 

TO: 

INFO (CC): 


1. Is there an EMERGENT/LIFE SAFETY Need: YESNO

2. City: 

2a. County: 

2b. State: 

2c. Territory: 

3. Reporting Grid Sq: 


4a. POTS landlines functioning? YESNOUnknown - N/A

4b. VOIP landlines functioning? YESNOUnknown - N/A

5a. Cell phone voice calls functioning? YESNOUnknown - N/A

5b. Cell phone texts functioning? YESNOUnknown - N/A

6. AM/FM Broadcast Stations functioning? YESNOUnknown - N/A

7a. OTA TV functioning? YESNOUnknown - N/A

7b. Satellite TV functioning? YESNOUnknown - N/A

7c. Cable TV functioning? YESNOUnknown - N/A

8. Public Water Works functioning? YESNOUnknown - N/A

9a. Commercial Power functioning? YESNOUnknown - N/A

9b. Commercial Power Stable? YESNO - Brown outs/blinking lightsUnknown - N/A

9c. Natural Gas Supply functioning? YESNOUnknown - N/A

10. Internet functioning? YESNOUnknown - N/A

11a. NOAA weather radio functioning? YESNOUnknown - N/A

11b. NOAA weather radio audio degraded? YESNOUnknown - N/A


12. Additional Comments: Brief summary of current situation - expected outage times, major observations, etc.


13. POC (Your Call Here)