1. Date/time report received___________________________________

2. Name of person reporting failure____________________________

Phone number of person reporting failure____________________

Address (if available)______________________________________

Name of original source/witness of report___________________

3. Is person reporting failure affiliated with local, county, state, or federal government? Yes/No

If yes, what agency or department?_________________________________________________

4. Name of dam ________________________________________________

County in which located ____________________________________

Name of river or stream ____________________________________

Name of nearest downstream town ____________________________

Name of dam owner (if known) _______________________________

Estimated time of failure __________________________________

Estimated breach width (if known) __________________________

Water surface elevation (if known) _________________________

Dam height (if known) ______________________________________

Type of dam (earthen, concrete, etc.) ______________________

5. Has any other government agency/department been notified by the person making the report?(Yes/No)

If yes, what agency/department? _________________________________________

6. If dam has not failed but may, get description of current dam condition (cracked, over-flowing top/around sides, washing sides, sand boils, etc.)______________________________________________________________________________



7. Obtain any additional data available




8. Notification of appropriate RFC and WRH/HSD_________________


VERIFICATION -- Required if person reporting failure is other than government agency.

Dam failure/potential verified with ___________agency/department.

Name of person in agency/department _____________________________


ACTION --- Determine whether:

- The dam has failed or failure is imminent.

- Dam has not failed but will probably fail within 12 hours.

- Dam has not failed but will probably fail and the failure is forecast to be greater than 12 hour after you were informed of the possibility.

Name of person completing this report____________________________