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West Virginia DOCUMENTATION OF DISASTER PROBLEMS AND RESOLUTIONS Date:____________ To:_________________________ Fax #:__________________________ # Pages:__________ From:_______________________ Phone #:________________________ State Agency Director:____________________________________________________ Local Agency Director:__________________________________________________________ WIC Clinic(s) Affected:_________________________________________________________ Date and Description of Disaster:__________________________________________________ Location where Water is provided: _________________________________________________ Location where Food is provided: __________________________________________________ List all disaster problems including WIC clinic, WIC staff, vendor, and participant. Write “Resolved” and the date of resolution on the line of the problem when it is resolved. Once a problem is marked as “Resolved”, omit the problem from the following lists. 1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________ 4.____________________________________________________________________________ 5.____________________________________________________________________________ 6.____________________________________________________________________________ 7.____________________________________________________________________________ 8.____________________________________________________________________________ 9.____________________________________________________________________________ 10.___________________________________________________________________________ 11.___________________________________________________________________________ 12.___________________________________________________________________________ Signed:_________________________________Date:__________________________________ Email/Fax0 daily to the State Agency Disaster Coordinator to report ongoing problems and resolutions until all problems are resolved or addressed