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State Logo ENVIRONMENTAL HEALTH ASSESSMENT FORM FOR SHELTERS <br />For Rapid Assessment of Shelter Conditions during Disasters <br />I • • <br />'Agency /Organization Name ________________________ _ 90 Jml'flidlate--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 J Special Needs ::. Other _________ 6ARC Facility ::-Yes _: No 'J Unk/NA 7ARC Code <br />8Date Shelter Opened __ / __ ! __ (mm/dd/yr) 9Date Assessed __ / __ / __ (mm/dd/yr) 10Time Assessed __ : __ 'J am •~ pm <br />1I Reason for Assessment _ Preoperational ::.·. Initial ,::. Routine ~Other _______________________ _ <br />I2 Location Name and Description --------------------------------------- <br />13Street Address -------------------------------------------- <br />14 City / County _____________ 15State 16Zip Code _____ 17Latitude/Longitude -----~} ____ _ <br />18 Facility Contact/ Title _________________ 19Facility Type :.: School . "Arena/Convention center _ Olhe r ____ _ <br />20 Phone ____ 21 Fax ___ ___ _ 22 E-mailorOtherContact __________ _ <br />23 Current Census 24 Estimated Capacity _____ 25 Number of Residents____ 26 Nu mber of Staff/ Volunteers ___ _ <br />Ill. FACILITY VIII. SOLID WASTE GENERATED <br />21 structural damage <br />2a security / law enforcement available <br />29 Water system operational <br />30Hot water available <br />31HVAC system operationa l <br />32Adequate ventilation <br />33 Adequate space per person <br />34 Free of injury /occupational hazards <br />35 F ree of pest / vector issues <br />36 Acceptable level of cleanliness <br />37Electrical grid system operational <br />38 Generator in use, 39 If yes, Type ___ _ <br />401 ndoor tempera ture <br />42 Served on site <br />43Safe food source <br />44 Adequate supply <br />45Appropriate storage <br />46Appropriate temperatures <br />47 Hand-washing facilities available <br />48Safe food handling <br />49Dishwashing facilities available <br />socIean kitchen area <br />58 Adequate laundry services <br />59 Adequate number of toilets <br />60Adequate number of showers <br />61 Adequate number of hand -w ashing stations <br />62 Hand-washing supplies available <br />63Toilet supplies available <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 />._7 Yes <br />::_; Yes <br />::.; Yes <br />::Yes <br />Yes <br />::.:Yes <br />:~Yes <br />.:: Yes <br />J Yes <br />;~ Yes <br />Yes <br />_ Yes <br />Yes <br />Yes <br />Yes <br />Yes <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 />;:; 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 />::No ::. Unk/NA <br />·::.. No ·J Unk/NA <br />·,No :: Unk/NA <br />:: No ::. Unk/NA <br />:: No -Unk/NA <br />~ No ,:: Unk/NA <br />~-= No -Unk/NA <br />J Unk/NA <br />,~No c. Unk/NA <br />No r Unk/NA <br />.1 No Unk/NA <br />J No Unk/NA <br />No Unk/NA <br />No Urik/NA <br />J No UnKINA <br />66 Adequate number of collection receptacles <br />67 Appropriate separation <br />68 Appropriate disposal <br />69A ppropriate storage <br />70Timely removal <br />71 T pes <br />72 Clean diaper-changing facilities <br />73Hand-washing facilit ie s ava ilable <br />74 Adequate toy hygiene <br />75 Safe toys <br />76 Clean food/bottle preparation area <br />77 Adequate child/caregiver ratio <br />18Acce table level of cleanliness <br />79Adequate number of cots/beds/mats <br />a0Adequate supply of bedding <br />81Bedding changed regularly <br />82Adequate spacing <br />83Aoceptable level of cleanliness <br />XI. COMPANION ANIMALS <br />84 Companion animals present <br />asAnimal care available <br />86 Designated animal area <br />87 Acceptab le level of cleanliness <br />Yes :-No .J Unk/NA <br />Yes -_No :: Unk/NA <br />: Yes -_, No .::: Unk/NA <br />-Yes :::No '.: Unk/NA <br />-·Yes ·: No : • Unk/NA <br />Yes ::.: No UrituNA <br />Yes -:: No Unk/NA <br />Yes -_ No Urik/NA <br />Yes . No Urik/NA <br />Yes .:: No <br />-: Yes ::.: No <br />J Yes := No Un k/NA <br />..J Yes :::No _ Unk/NA <br />Yes ::. No Unk/NA <br />Yes .:; No lJnk/NA <br />":Yes ""No Unk/NA <br />Yes 1::. No •::. Unk/NA <br />·ves ~No -unk/NA <br />Yes ~ No Unk/NA <br />88