DAM FAILURE / POTENTIAL DAM FAILURE REPORT LOG
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____________________________