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State Logo ENVIRONMENTAL HEALTH ASSESSMENT FORM FOR SHELTERS <br />For Rapid Assessment of Shelter Conditions during Disasters <br />I. ASSESSING AGENCY DATA <br />'Agency /Organization Name _______________________ _ 90lmmediate Needs Identified: DYes D No <br />2Assessor NamelTitle ________________________________________ _ <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 i No =. Unk/NA 7ARC Code __ _ <br />8Date Shelter Opened __ 1 __ 1 __ (mm/dd/yr) 9Date Assessed __ 1 __ 1 __ (mm/dd/yr) 10Time Assessed _ _ _ _ : am pm <br />11Reason for Assessment 'Preoperational ,Initial ::: Routine:.: Other _______________________ _ <br />12Location Name and Description _____________________________________ _ <br />13StreetAddress __________________________________________ _ <br />14City / County _____________ 15State 16Zip Code _____ 17Latitude/Longitude _____ --1, ____ _ <br />18Facility Contact / Title ________________ _ 19Facility Type :::: School,:: Arena/Convention center ~'Ql h er. ____ _ <br />22E-mail or Other Contact __________ _ 20Phone _____ _ ____ 21Fax __ _ 9 ------- <br />23Current Census ===== 24Estimated Capac ty,~====-c 25Number of Residents _______ ____ 26Number of Staff / Volunteers ___ _ <br />III. FACILITY VIII. SOLID WASTE GENERATED <br />27Structural damage <br />28Security / law enforcement available <br />29Water system operational <br />30Hot water available <br />31HVAC system operational <br />32Adequate ventilation <br />33Adequate space per person <br />34Free of injury /occupational hazards <br />35Free of pest / vector issues <br />36Acceptable level of cleanliness <br />37Electrical grid system operational <br />38Generator in use, 391f yes, Type <br />4olndoor <br />43Safe food source <br />44Adequate supply <br />45Appropriate storage <br />46Appropriate temperatures <br />47Hand-washing facilities available <br />48Safe food handling <br />49Dishwashing facilities available <br />50Clean kitchen area <br />55 Reported outbreaks, unusual illness / injuries <br />56Medical care services on site <br />57Counse ll ng services available <br />VII. SANITATION <br />58Adequate laundry services <br />59Adequate number of toilets <br />60Adequate number of showers <br />61Adequate number of hand-washing stations <br />62Hand-washing supplies available <br />63Toilet supplies available <br />~ Yes <br />.: Yes <br />:: Yes <br />.' Yes <br />I Yes <br />i Yes <br />I Yes <br />Yes <br />Yes <br />Yes <br />= Yes <br />_ Yes <br />J Yes <br />::J Yes <br />JYes <br />.~ Yes <br />•• Yes <br />Yes <br />Yes <br />Yes <br />-' Yes <br />Yes ' <br />Yes <br />'y:es <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />No <br />No <br />No <br />No <br />No <br />No <br />No <br />No <br />No <br />No <br />No <br />No <br />:: No <br />C No <br />':1 No <br />., No <br />No <br />No <br />I No <br />No <br />; No <br />., No <br />[~ No <br />", No <br />No <br />No <br />No <br />No <br />No <br />No <br />.' Unk/NA <br />Unk/NA <br />" Un kiNA <br />Unk/NA <br />Unk/NA <br />Unk/NA <br />Unk/NA <br />, Unk/NA <br />•• Unk/NA <br />:: Unk/NA <br />.:: Unk/NA <br />,= Unk/NA <br />== Unk/NA <br />J Unk/NA <br />,.: Unk/NA <br />'" Unk/NA <br />' Unk/NA <br />Unk/NA <br />Unk/NA <br />Unk/NA <br />.:. Unk/NA <br />Un ki NA <br />Un ki NA <br />Uri ki NA <br />Unk /NA <br />IJn kl NA <br />Un kJ NA <br />Unki NA <br />Un kt NA <br />Un ki NA <br />66Adequate number of collection receptacles <br />67 Appropriate separation <br />68Appropriate disposal <br />69Appropriate storage <br />70Timely removal <br />72Clean diaper-changing facilities <br />73Hand-washing facilities available <br />74Adequate toy hygiene <br />75Safe toys <br />76Clean food/boUle preparation area <br />77 Adequate child/caregiver ratio taili level of cleanliness <br />79Adequate number of cots/beds/mats <br />80Adequate supply of bedding <br />818edding changed regularly <br />8,2Adequate spacing <br />83A~ptab~e level of cleanliness <br />XI. COMPANION ANIMALS <br />84Companion animals present <br />85Animal care available <br />86Designated animal area <br />Yes <br />Yes <br />Yes <br />Ye s <br />Ye,S <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />= Yes <br />'_: Yes <br />= Yes <br />= Yes <br />:: Yes <br />Yes <br />Yes <br />Yes <br />~I o _ Unk/NA <br />No .= Unk/NA <br />No :: Unk/NA <br />No '.: Unk/NA <br />No = Unk/NA <br />No Un l</N A <br />No Unki NA <br />No Unk/NA <br />No Unki NA <br />No <br />No <br />~ No ,== Unk/NA <br />= No = Unk/NA <br />= No :: Unk/NA <br />== No :: Unk/NA <br />[ No :: Unk/NA <br />No "Unk/NA <br />No Unk/NA <br />Unk/NA <br />88