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State Logo ENVIRONMENTAL HEALTH ASSESSMENT FORM FOR SHELTERS <br />'Agency /Organization Name _______________________ _ <br />2Assessor NamelTitle ________________________________________ _ <br />3Phone 4Email or Other Contact <br />II. FACILITY TYPE, NAME AND CENSUS DATA <br />5Shelter Type [] Community/Recovery 0 Special Needs 0 Other BARC Facility 0 Ves J No [] Unk/NA 7ARC Code __ _ <br />80ate Shelter Opened __ 1 __ 1 __ (mm/dd/yr) 90 ate Assessed __ 1 __ 1 __ (mm/dd/yr) 10Time Assessed __ : __ ::J am [] pm <br />l l Reason for Assessment [] Preoperational [] Initial C Routine [] Other _______________________ _ <br />12Location Name and Description ______________________________________ _ <br />13StreetAddress __________________________________________ _ <br />14City/County _____________ 15State 1BZipCode _____ 17Latitude/Longitude _____ -' _____ _ <br />18Facility Contact / Title _________________ 19Facility Type '::1 School 0 Arena/Convention center e Other ____ _ <br />20 Phone __ _ ____ 21Fax ______ -___ _ 22E-mailorOtherContact __________ _ <br />23Cur rent Census ====""'"' 24Estimated CapaclW ===== 25Number of Residents ==== 26Number of Staff / Volun teers ==-__ <br />III. FACILITY VIII. SOLID WASTE GENERATED <br />27Structural damage <br />28Security / law enforcement available <br />29 Water system operational <br />3O Hot water available <br />31HVAC system operational <br />32Adequate ventilation <br />33 Adequate space per person <br />34Free of injury loccupational hazards <br />35 Free of pest I vector issues <br />36Acceptable level of cleanliness <br />37Electrical grid system operational <br />38Generator in use , 39 If yes , Type <br />4olndoor te <br />43Safe food source <br />44Adequate supply <br />45Appropriate storage <br />46Appropriate temperatures <br />47Hand-washing facilities available <br />48Safe food handling <br />490ishwashing facilities available <br />50Clean kitchen area <br />53Safe water source <br />54Safe ice source <br />55Reported outbreaks, unusual illness I injuries <br />56Medical care services on site <br />v v'u ';)."J IIl,! services available <br />58Adequate laundry services <br />59Adequate number of toilets <br />BOAdequate number of showers <br />B1Adequate number of hand-washing stations <br />62Hand-washing supplies available <br />63Toilet supplies available <br />o Ves ::: No <br />D Yes o No <br />O Ves [j No <br />O Ves r:J No <br />O Ves e No <br />D Yes ::J No <br />D Yes ::J No <br />O Ves [J No <br />I::J Yes e No <br />fJ Ves LJ No <br />[] Ves o No <br />D Ves D No <br />[] Ves O No <br />D Yes O No <br />D Ves O No <br />D Yes O No <br />DVes D No <br />D Ves <br />[j Ves <br />O Ves <br />::Ves e No <br />C':: Yes CJ No <br />e Yes ::J No <br />o Yes O No <br />e Ves D No <br />e Ves o No <br />J Unk/NA <br />o Unk/NA <br />o Unk/NA <br />u Unk/NA <br />o Unk/NA <br />2 Unk/NA <br />:J Unk/NA <br />:::; Unk/NA <br />o Unk /NA <br />[] Unk/NA <br />[1 Unk/NA <br />D Unk/NA <br />[J Unk/NA <br />[] Unk/NA <br />CJ Unk /NA <br />[] Unk/NA <br />[] Unk/NA <br />D Unk /NA <br />'J Un kiNA <br />C Unk/NA <br />o UnkiNA <br />[] Unk/NA <br />C Un k/NA <br />[J Unk/NA <br />66Adequate number of collection receptacles 'J Ves C No C Unk/NA <br />67 Appropriate separation O Ves [] No Ll Unk/NA <br />68Appropriate disposal O Ves D No D Unk /NA <br />69Appropriate storage e Ves D No o Unk/NA <br />70Timely removal C Yes [j No I] Unk/NA <br />71 Types J Solid [] Hazardous [] Medical J Unk/NA <br />IX . CHILDCARE AREA <br />72Clean diaper -changing facilities <br />73Hand-washing facilit ies available <br />74Adequate toy hygiene <br />75Safe toys <br />76Clean food/bottle preparation area <br />77 Adequate child/caregiver ratio <br />D Ves e No o Unk /NA <br />O Ves D No D Unk/NA <br />r::: Yes [] No o Unk/NA <br />[] Yes o No LJ Unk/NA <br />::J Yes r:J No ::J Unk/NA <br />Ll Yes o Unk/NA <br />u Ves [j No :] Unk/NA <br />i= Ves 0 No 0 Unk/NA <br />[J Ves 0 No [] Unk/NA <br />8S