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88 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />State Logo ENVIRONMENTAL HEALTH ASSESSMENT FORM FOR SHELTERS <br />For Rapid Assessment of Shelter Conditions during Disasters <br />I. ASSESSING AGENCY DATA <br />¹Agency /Organization Name ___________________________________________________________________ 90Immediate Needs Identified:  Yes  No <br />2Assessor Name/Title ___________________________________________________________________________________________________________________ <br />3Phone __ __ __ - __ __ __ - __ __ __ __ 4Email or Other Contact ____________________________________________________________________ <br />II. FACILITY TYPE, NAME AND CENSUS DATA <br />5Shelter Type  Community/Recovery  Special Needs  Other _______________________ 6ARC Facility  Yes  No  Unk/NA 7ARC Code ________ <br />8Date Shelter Opened __ __ /__ __/__ __ (mm/dd/yr) 9Date Assessed __ __ /__ __/__ __ (mm/dd/yr) 10Time Assessed __ __ : __ __  am  pm <br />11Reason for Assessment  Preoperational  Initial  Routine  Other __________________________________________________________________ <br />12Location Name and Description ___________________________________________________________________________________________________________ <br />13Street Address ________________________________________________________________________________________________________________________ <br />14City / County ____________________________________ 15State __ __ 16Zip Code __ __ __ __ __ 17Latitude/Longitude ________________/_______________ <br />18Facility Contact / Title _______________________________________________ 19Facility Type  School  Arena/Convention center  Other______________ <br />20Phone __ __ __ - __ __ __ - __ __ __ __ 21Fax __ __ __ - __ __ __ - __ __ __ __ 22E-mail or Other Contact _______________________________ <br />23Current Census _____________ 24Estimated Capacity ______________ 25Number of Residents ____________ 26Number of Staff / Volunteers __________ <br />III. FACILITY VIII. SOLID WASTE GENERATED <br />27Structural damage  Yes  No  Unk/NA 66Adequate number of collection receptacles  Yes  No  Unk/NA <br />28Security / law enforcement available  Yes  No  Unk/NA 67Appropriate separation  Yes  No  Unk/NA <br />29Water system operational  Yes  No  Unk/NA 68Appropriate disposal  Yes  No  Unk/NA <br />30Hot water available  Yes  No  Unk/NA 69Appropriate storage  Yes  No  Unk/NA <br />31HVAC system operational  Yes  No  Unk/NA 70Timely removal  Yes  No  Unk/NA <br />32Adequate ventilation  Yes  No  Unk/NA 71Types  Solid  Hazardous  Medical  Unk/NA <br />33Adequate space per person  Yes  No  Unk/NA IX. CHILDCARE AREA <br />34Free of injury /occupational hazards  Yes  No  Unk/NA 72Clean diaper-changing facilities  Yes  No  Unk/NA <br />35Free of pest / vector issues  Yes  No  Unk/NA 73Hand-washing facilities available  Yes  No  Unk/NA <br />36Acceptable level of cleanliness  Yes  No  Unk/NA 74Adequate toy hygiene  Yes  No  Unk/NA <br />37Electrical grid system operational  Yes  No  Unk/NA 75Safe toys  Yes  No  Unk/NA <br />38Generator in use, 39 If yes, Type__________  Yes  No  Unk/NA 76Clean food/bottle preparation area  Yes  No  Unk/NA <br />40Indoor temperature _________ oF  Yes  No  Unk/NA 77Adequate child/caregiver ratio  Yes  No  Unk/NA <br />IV. FOOD 78Acceptable level of cleanliness  Yes  No  Unk/NA <br />41Preparation on site  Yes  No  Unk/NA X. SLEEPING AREA <br />42Served on site  Yes  No  Unk/NA 79Adequate number of cots/beds/mats  Yes  No  Unk/NA <br />43Safe food source  Yes  No  Unk/NA 80Adequate supply of bedding  Yes  No  Unk/NA <br />44Adequate supply  Yes  No  Unk/NA 81Bedding changed regularly  Yes  No  Unk/NA <br />45Appropriate storage  Yes  No  Unk/NA 82Adequate spacing  Yes  No  Unk/NA <br />46Appropriate temperatures  Yes  No  Unk/NA 83Acceptable level of cleanliness  Yes  No  Unk/NA <br />47Hand-washing facilities available  Yes  No  Unk/NA XI. COMPANION ANIMALS <br />48Safe food handling  Yes  No  Unk/NA 84Companion animals present  Yes  No  Unk/NA <br />49Dishwashing facilities available  Yes  No  Unk/NA 85Animal care available  Yes  No  Unk/NA <br />50Clean kitchen area  Yes  No  Unk/NA 86Designated animal area  Yes  No  Unk/NA <br />V. DRINKING WATER AND ICE 87Acceptable level of cleanliness  Yes  No  Unk/NA <br />51Adequate water supply  Yes  No  Unk/NA XII. OTHER CONSIDERATIONS <br />52Adequate ice supply  Yes  No  Unk/NA 88Handicap accessibility  Yes  No  Unk/NA <br />53Safe water source  Yes  No  Unk/NA 89Designated smoking areas  Yes  No  Unk/NA <br />54Safe ice source  Yes  No  Unk/NA XIII. COMMENTS (List Critical Needs on Immediate Needs Sheet) <br />VI. HEALTH / MEDICAL __________________________________________________________________ <br />55Reported outbreaks, unusual illness / injuries  Yes  No  Unk/NA __________________________________________________________________ <br />56Medical care services on site  Yes  No  Unk/NA __________________________________________________________________ <br />57Counseling services available  Yes  No  Unk/NA __________________________________________________________________ <br />VII. SANITATION __________________________________________________________________ <br />58Adequate laundry services  Yes  No  Unk/NA __________________________________________________________________ <br />59Adequate number of toilets  Yes  No  Unk/NA __________________________________________________________________ <br />60Adequate number of showers  Yes  No  Unk/NA __________________________________________________________________ <br />61Adequate number of hand-washing stations  Yes  No  Unk/NA __________________________________________________________________ <br />62Hand-washing supplies available  Yes  No  Unk/NA __________________________________________________________________ <br />63Toilet supplies available  Yes  No  Unk/NA __________________________________________________________________ <br />64Acceptable level of cleanliness  Yes  No  Unk/NA __________________________________________________________________ <br />65Sewage system type  Community  On site  Portable  Unk/NA <br />