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Slate Logo ENVIRONMENTAL HEALTH ASSESSMENT FORM FOR SHELTERS <br />For Assessment of Shelter Conditions durin Disasters ffi <br />eolmmediate Needs ldentified: tr Yes ! No <br />2Assessor Name/Title <br />3Phone 4Email or Other Contact <br />'Agency /Organization Name <br />sDateShelterOpened __/_ _l__ (mm/dd/yr) eDateAssessed __l__l__ (mm/dd/yr) toTimeAssessed <br />--:-- !am!pm <br />2sNumber of Residents zoNumber of Staff / Volunteers _ <br />teFacility Contact / Title <br />14City / County <br />23Current Census 2aEstimated Capacity <br />20Phone 2lFax <br />l2Location Name and Description <br />l3Street Address <br />leFacilitv Tvoe ! School n Arena/Convention center ! Other <br />22E-mail or Other Contact <br />llReason for Assessment ! Preoperational ! lnitial ! Routine I Other <br />sShelter Type ! Community/Recovery n Special Needs ! Other 0ARC Facility n Yes ! No I Unk/NA TARC Code _ <br />lsState __ l6ZipCode-- lTlatitude/Longitude <br />66Adequate number of collection receplacles <br />6TAppropriate separation <br />6sAppropriate disposal <br />6eAppropriate storage <br />ToTimely removal <br />N YeS <br />I Yes <br />! Yes <br />! Yes <br />I Yes <br />!No <br />nNo <br />nNo <br />!No <br />!No <br />tr UNK/NA <br />r-t Unk/NA <br />! UNK/NA <br />N UNK/NA <br />! UNK/NA <br />11r ! Solid n Hazardous ! Medical <br />2TStructural damage <br />2sSecurity / law enforcement available <br />2eWater system operational <br />3oHot water available <br />31 HVAC system operational <br />32Adequate ventilation <br />33Adequate space per person <br />3aFree of injury /occupational hazards <br />3sFree of pest / vector issues <br />36Acceptable level of cleanliness <br />3TElectrical grid system operational <br />3sGeneralor in use, 3s lf yes, Type- <br />! Yes <br />! Yes <br />n Yes <br />tr Yes <br />! Yes <br />N YeS <br />I Yes <br />! Yes <br />n Yes <br />I Yes <br />! Yes <br />tl Yes <br />nNo <br />!No <br />nNo <br />!No <br />lNo <br />nNo <br />1-l No <br />!No <br />!No <br />!No <br />!No <br />nNo <br />tr UNK/NA <br />N UNK/NA <br />tl unk/NA <br />N UNK/NA <br />N UNUNA <br />N UNK/NA <br />r Unk/NA <br />! UNK/NA <br />I UNK/NA <br />I UNK/NA <br />N UNUNA <br />N UNK/NA <br />! UNK/NAaolndooroF <br />T2Clean diaper-changing facilities <br />73Hand-washing facilities available <br />T4Adequate toy hygiene <br />7sSafe toys <br />T6Clean food/bottle preparation area <br />TTAdequate child/caregiver ratio <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />n <br />tr <br />n <br />! <br />n <br />! <br />n <br />No ! Unk/NA <br />No r-l Unk/NA <br />No n Unk/NA <br />No ! Unk/NA <br />No ! UnUNA <br />No n Unk/NA <br />No I Unk/NAlevel of cleanliness <br />TsAdequate number of cots/beds/mats <br />soAdequate supply of bedding <br />stBedding changed regularly <br />s2Adequate spacing <br />tr Yes <br />! Yes <br />! YeS <br />n Yes <br />N YeS <br />nNo <br />trNo <br />!No <br />!No <br />INo <br />N UNK/NA <br />! UNK/NA <br />! UNK/NA <br />N UNK/NA <br />! UNK/NAlevel of cleanliness <br />! Yes <br />! Yes <br />! Yes <br />I Yes <br />! Yes <br />I Yes <br />n Yes <br />! Yes <br />N YeS <br />N YeS <br />4lPreparation on site <br />a2Served on site <br />43Safe food source <br />4Adequate supply <br />45Appropriate storage <br />46Appropriate temperatu res <br />aTHand-washing facilitics availablc <br />48Safe food handling <br />4sDishwashing facilities available <br />soClean kitchen area <br />!No <br />nNo <br />nNo <br />nNo <br />nNo <br />nNo <br />nNo <br />nNo <br />!No <br />DNO <br />! UNK/NA <br />t] unk/NA <br />N UNKiNA <br />! UNK/NA <br />N UNK/NA <br />N UNK/NA <br />N UNK/NA <br />! UNK/NA <br />N UNK/NA <br />! UNK/NA <br />eCompanion animals present <br />ssAnimal care available <br />soDesignated animal area <br />! Yes <br />! Yes <br />! YeS <br />! Yes <br />!No <br />!No <br />nNo <br />! UNK/NA <br />! UNK/NA <br />r unk/NA <br />l(/NA87level of cleanliness <br />osHandicap accessibility N YeS <br />! YeS <br />!No <br />nNo <br />tr UNK/NA <br />! UNK/NAareas <br />5lAdequate waler supply <br />s2Adequate ice supply <br />53Safe water source <br />saSafe ice source <br />I Yes <br />N YeS <br />! Yes <br />! YeS <br />I No ! UnUNA <br />! No n Unk/NA <br />! No n Unk/NA <br />n No n Unk/NA <br />s5Reported outbreaks, unusual illness / injuries <br />56Medical care services on site <br />lYes n <br />!Yes ! <br />!Yes ! <br />No n UnkiNA <br />No n UnkiNA <br />Nonservices available <br />I. ASSESSING AGENCY DATA <br />II. FACILITY TYPE, NAME AND CENSUS DATA <br />III. FACILITY VIII. SOLID WASTE GENERATED <br />IX. CHILDCARE AREA <br />X. SLEEPING AREA <br />IV. FOOD <br />V. DRINKING WATER AND ICE <br />VI. HEALTH / MEDICAL <br />VII. SANITATION <br />XI. COMPANION ANIMALS <br />XII. OTHER CONSIDERATIONS <br />XIII. COMMENTS ist Critical Needs on lmmediate Needs <br />ssAdequate laundry services <br />seAdequate number of toilets <br />ooAdequate number of showers <br />n <br />! <br />n <br />! <br />! <br />! <br />n <br />! <br />n <br />Yes <br />Yes <br />Yes <br />No <br />No <br />No <br />f,t^ <br />UnldNA <br />Unk/NA <br />Unl</NA <br />61 A n^^,,^l^ ^' '-h^r n{ h anel ..,^.hi^^ ^r^ri^^^