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State Logo ENVIRONMENTAL HEAL TH ASSESSMENT FORM FOR SHELTERS <br />For Rapid Assessment of Shelter Conditions during Disasters <br />•Yes D No <br />2Assessor Name/Title ------------------------------------------ <br />3Phone 4Email or Other Contact <br />II. FACILITY TYPE, NAME AND CENSUS DATA <br />5Shelter Type -J Community/Recovery :: Special Needs ::: Other ________ 6ARC Facility ::: Yes ,:::: No lJ Unk/NA 7 ARC Code <br />8DateShelterOpened __ ! __ ! __ (mm/dd/yr) 9DateAssessed __ ! __ ! __ (mm/dd/yr) 10TimeAssessed __ : __ -:.:Jam'Jpm <br />11 Reason for Assessment ~~ Preoperational ::J Initial ,J Routine ,::: Other _______________________ _ <br />12 Location Name and Description --------------------------------------- <br />13Street Address -------------------------------------------- <br />14City /County _____________ 15State 16ZipCode _____ 17 Latitude/Longitude _____ ___, _____ _ <br />18 Facility Contact/ Title _________________ 19 Facility Type :: School :-:: Arena/Convention center ::: Other ____ _ <br />20 Phone ____ 21Fax ___ -___ -___ _ 22E-mailorOtherContact __________ _ <br />23 Current Census ____ _ 24 Estimated Capacity _____ 25 Number of Residents _____ 26 Number of Staff/ Volunteers ___ _ <br />Ill. FACILITY VIII. SOLID WASTE GENERATED <br />27Structural damage ·::: Yes ::: No c Unk/NA 66 Adequate number of collection receptacles JYes _ Na _1 Unk/NA <br />28 Security / law enforcement available :::Yes ,::;; No ,::1 Unk/NA 67 Appropriate separation 'J Yes No Unk/NA <br />29 Water system operational JYes cNo :7 Unk/NA 68Appropriate disposal ::J Yes No Unk/NA <br />J0Hot water available J Yes CNo J Unk/NA B9Appropriate storage -::i Yes _No Unk/NA <br />31 HVAC system operational JYes J No =: Unk/NA 70 Timely removal ::: Unk/NA <br />32 Adequate ventilation ::1 Yes ,::; No ::: Unk/NA 111 ·es <br />33 Adequate space per person ::: Yes J No , Unk/NA <br />34 Free of injury /occupational hazards '~'. Yes J No ·unk/NA 72 Clean diaper-changing facilities Yes ::: No ::: Unk/NA <br />35 Free of pest/ vector issues •= Yes 7 No J Unk/NA 73 Hand-washing facilities available Yes ::: No -· Unk/NA <br />36 Acceptable level of cleanliness ,:::Yes JNo =: Unk/NA 74 Adequate toy hygiene Yes J No :J Unk/NA <br />37 Electrical grid system operational :::: Yes ::7 No •::: Unk/NA 75 Safe toys ~Yes :JNo =i Unk/NA <br />38 Generator in use, 39 If yes, Type ·JYes :::JNo ,::: Unk/NA 76 Clean food/bottle preparation area Yes J No Ci Unk/NA <br />77 Adequate child/caregiver ratio Yes ;::: No <br />·73Aoc eptabla level of cleanliness <br />:::Yes CNo ·:::, Unk/NA 79 Adequate number of cots/beds/mats :J Yes •J No C Unk/NA <br />43Safe food source ::iYes C No Ci Unk/NA a0Adequate supply of bedding .JYes J No C Unk/NA <br />44 Adequate supply J Yes CJ No J Unk/NA a1sedding changed regularly :J Yes CJ No c Unk/NA <br />45 Appropriate storage JYes CJ No C Unk/NA 82 Adequate spacing ::JYes J No C Unk/NA <br />46Appropriate temperatures :::iYes .J No :7 Unk/NA ~Accepla b!a level of cleanliness JYes :J No 1::: Unk/NA <br />47 Hand-washing facilities available :::Yes J No c:: Unk/NA I XI. COMPANION ANIMALS <br />48Safe food handling r:::Yes ::: No C Unk/NA 84Companion animals present cYes J No :::: Unk/NA <br />49 Dishwashing facilities available ,::; Yes J No C Unk/NA 85 Animal care available :::Yes ,_:: No ,::; Unk/NA <br />5°Clean kitchen area cYes Ci No C Unk/NA ,::; Yes C No '.: Unk/NA <br />58 Adequate laundry services c:i Yes CJ No c Unk/NA <br />59 Adequate number of toilets :::-Yes c::J No C Unk/NA <br />60 Adequate number of showers c Yes J No :J Unk/NA <br />61 Adequate number of hand-washing stations :::Yes J No =J Unk/NA <br />62 Hand-washing supplies available :~Yes =1 No c: Unk/NA <br />63 Toilet supplies available -·Yes cNo :J Unk/NA <br />88