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HomeMy WebLinkAboutAmerican Red Cross Facility Use AgreementAmerican Red Cross Facility Use Agreement The American National Red Cross ('Red Cross "), a non - profit corporation chartered by the United States Congress, provides services to individuals, families and communities when disasters strike. The disaster relief activities of the Red Cross are made possible by the American public who support the Red Cross with generous donations. The Red Cross's disaster services are also supported by facility owners who permit the Red Cross to use their buildings as shelters and other service delivery sites for disaster victims. This agreement is between the Red Cross and a facility owner ( "Owner') so the Red Cross can use the facility to provide services during a disaster. This agreement only applies when Red Cross requests use of the facility and is managing the activity at the facility. Parties and Facility Owner: Full Name of Owner tXW 0 pve_Y n Address go GO-4e_YhM artcf 1�t(11 1J�' 2s�i 24 -Hour Point of Contact u)Qr1Cia (nodiv%o VVb —,A`J' orty —V\'t OY Name and Title Work Phone Cell Phone a1 \�'y1�' cmo\ Address for Ofrical Notices (only if different American Red Cross, Disaster Cycle Services Logistics, 8550 Arlington Blvd., from above address) Fairfax, VA 22031 Red Cross: Chapter Name Chapter Address 24 -Hour Point of Contact (1 v1 OV vl,S 0 A, sillc��r r �r1�gpX Name and Title Work Phone Cell Phone Address for Official American Red Cross, Disaster Cycle Services Logistics, 8550 Arlington Blvd., Notices Fairfax, VA 22031 Facility.: Insert name and complete street address of building or, if multiple buildings, write "See attached facility list," and attach facility list, including complete street address of each building that is part of this agreement. If the Red Cross will use only a portion of a building, then describe the portion of the building that the Red Cross will use. See �iS•t provided � �r • �ohr�oc� DMWT Facility Use Agreement JT V.2.0 2017.06.29 jev vicez 2..�� -21e3 32� �� Ac���- � °h��l �� C,�oss ��°``a �� Shoo\ ���a ��M 9�`� ��03 +American l Red Cross Terms and Conditions Facility Use Agreement 1. Use of Facility: Upon request and if feasible, Owner will permit the Red Cross to use and occupy the Facility on a temporary basis to conduct emergency, disaster - related activities. The Facility may be used for the following purposes (both parties must initial all that apply): Facility Purpose Owner Initials Red Cross Initials Service Center (Operations, Client Services, or Volunteer Intake) Storage of supplies Parking of vehicles Disaster Shelter 2. Facility Management: The Red Cross will designate a Red Cross official to manage the activities at the Facility ( "Red Cross Manager'). The Owner will designate a Facility Coordinator to coordinate with the Red Cross Manager regarding the use of the Facility by the Red Cross. 3. Condition of Facilitv: The Facility Coordinator and Red Cross Manager (or designee) will jointly conduct a survey of the Facility before it is turned over to the Red Cross. They will use the first page of the Red Cross's Facility/Shelter Opening/Closing Form to record any existing damage or conditions. The Facility Coordinator will identify and secure all equipment in the Facility that the Red Cross should not use. The Red Cross will exercise reasonable care while using the Facility and will not modify the Facility without the Owners express written approval. Food Services (This paragraph applies only when the Facility is used as a shelter or service center): Upon request by the Red Cross, and if such resources are available, the Owner will make the food service resources of the Facility, including food, supplies, equipment and food service workers, available to feed the shelter occupants. The Facility Coordinator will designate a Food Service Manager to coordinate meals at the direction of and in cooperation with the Red Cross Manager. The Food Service Manager will establish a feeding schedule and supervise meal planning and preparation. The Food Service Manager and Red Cross Manager will jointly conduct a pre - occupancy inventory of the food and food service supplies before the Facility is turned over to the Red Cross. When the Red Cross vacates the Facility, the Red Cross Manager and Facility Coordinator or Food Service Manager will conduct a post- occupancy inventory of the food and supplies used during the Red Cross's activities at the Facility. 5. Custodial Services (This paragraph applies only when the Facility is used as a shelter or service center.): Upon request of the Red Cross and if such resources are available, the Owner will make its custodial resources, including supplies and workers, available to provide cleaning and sanitation services at the Facility. The Facility Coordinator will designate a Facility Custodian to coordinate the these services at the direction of and in cooperation with the Red Cross Manager. 6. Security /Safety: In coordination with the Facility Coordinator, the Red Cross Manager, as he or she deems necessary and appropriate, will coordinate with law enforcement regarding any security and safety issues at the Facility. 7. Sianaae and Publicity: The Red Cross may post signs identifying the Facility as a site of Red Cross operations in locations approved by the Facility Coordinator. The Red Cross will remove such signs when the Red Cross concludes its activities at the Facility. The Owner will not issue press releases or other publicity concerning the Red Cross's activities at the Facility without the written consent of the Red Cross Manager. The Owner will refer all media questions about the Red Cross activities to the Red Cross Manager. DMWT Facility Use Agreement JT V.2.0 2017.06.29 American Red Cross Facility Use Agreement 8. Closing the Facility: The Red Cross will notify the Owner or Facility Coordinator of the date when the Red Cross will vacate the Facility. Before the Red Cross vacates the Facility, the Red Cross Manager and Facility Coordinator will jointly conduct a post- occupancy inspection, using the second page of the She/terlFacility Opening/Closing Form, to record any damage or conditions. 9. Fee (This paragraph does not apply when the Facility is used as a shelter. The Red Cross does not pay fees to use facilities as shelters.): Both parties must initial one of the two statements below: a. Owner will not c)aa{ge a fee for the use of tjte, cility. Owner initials: /b1�' Red Cross initials: �� The Red Cross will pay $ per day /week/month (circle one) for the right to use and occupy the Facility. Owner initials: Red Cross initials: 10. Reimbursement: Subject to the conditions in paragraph 10(e) below, the Red Cross will reimburse the Owner for the following: Damage to the Facility or other property of Owner, reasonable wear and tear excepted, resulting from the operations of the Red Cross. Reimbursement for facility damage will be based on replacement at actual cash value. The Red Cross, in consultation with the Owner, will select from bids from at least three reputable contractors. The Red Cross is not responsible for storm damage or other damage caused by the disaster. Reasonable costs associated with custodial and food service personnel and supplies which would not have been incurred but for the Red Cross's use of the Facility. The Red Cross will reimburse at per -hour, straight -time rate for wages actually incurred but will not reimburse for (i) overtime or (ii) costs of salaried staff. Reasonable, actual, out -of- pocket costs for the utilities indicated below, to the extent that such costs would not have been incurred but for the Red Cross's use of the Facility. (Both parties must initial all utilities that may be reimbursed by the Red Cross): The Owner will submit any request for reimbursement to the Red Cross within 60 days after the occupancy of the Red Cross ends. Any request for reimbursement must be accompanied by supporting invoices. Any request for reimbursement for personnel costs must be accompanied by a list of the personnel with the dates and hours worked. If the disaster is a Federally - declared disaster and Owner is a municipal or state government entity, then the Owner will work with appropriate emergency management agencies to seek cost reimbursement through the Federal Emergency Management Agency's program for administering Public Assistance Category B under the Robert T. Stafford Act. The Red Cross is not obligated to reimburse the Owner for costs covered by Public Assistance Category B. Insurance: The Red Cross shall carry insurance coverage in the amounts of at least $1,000,000 per occurrence for Commercial General Liability and Automobile Liability. The Red Cross shall also carry Workers' Compensation coverage with statutory limits for the jurisdiction within which the facility is located and $1,000,000 in Employers' Liability. DMWT Facility Use Agreement JT V.2.0 2017.06.29 Owner Initials Red Cro s Initials Water CL Gas CC. Electricity 'C ry Waste Disposal 0 C The Owner will submit any request for reimbursement to the Red Cross within 60 days after the occupancy of the Red Cross ends. Any request for reimbursement must be accompanied by supporting invoices. Any request for reimbursement for personnel costs must be accompanied by a list of the personnel with the dates and hours worked. If the disaster is a Federally - declared disaster and Owner is a municipal or state government entity, then the Owner will work with appropriate emergency management agencies to seek cost reimbursement through the Federal Emergency Management Agency's program for administering Public Assistance Category B under the Robert T. Stafford Act. The Red Cross is not obligated to reimburse the Owner for costs covered by Public Assistance Category B. Insurance: The Red Cross shall carry insurance coverage in the amounts of at least $1,000,000 per occurrence for Commercial General Liability and Automobile Liability. The Red Cross shall also carry Workers' Compensation coverage with statutory limits for the jurisdiction within which the facility is located and $1,000,000 in Employers' Liability. DMWT Facility Use Agreement JT V.2.0 2017.06.29 American Red Cross Facility Use Agreement 12. Indemnification: The Red Cross shall defend, hold harmless, and indemnify Owner against any legal liability, including reasonable attorney fees, in respect to claims for bodily injury, death, and property damage arising from the negligence of the Red Cross during the use of the Facility. 13. Term: The term of this agreement begins on the date of the last signature below and ends 30 days after written notice by either party. A-)QIJJ NQC,oveY COUC1 OwpW (Legal N m) / By (Signature) C�)YiS Couay'll! C Name (Printed) Title Date DMWT Facility Use Agreement JT V.2.0 2017.06.29 The American National Red Cross (L al Name) By (Sign re) r �VIVIL�ien�-f°rct R Jc�ris1571n. Name (Printed) Title /� or/ Date + C: Shelter Facility Survey Site Name / n NSS ID# Date School District SAS Name of T 1� 1 ( S I �' building ,� u `� � SS 4-. +� — <.M Building # of Phone # Ot I p 3SD Zo72Fax # Website �,j � �. . N i-1,C S vIT Shelter address >{ 3 DS S \^ ' P \�w C L `I Town/ \ County/ State K�C Zip City ^` ^��u "� Parish Code Z- 9,4iZ Mailing Address (if different) Town/ County/ State Zip City Parish Code Agency operating shelter Red ❑ FEMA ❑ DHS ❑ TSA ❑ SBC F- Other (check one) 'Cross Shelter agency type Red Cross 11 Red Cross El Red Cross ❑ Independent (check one) anaged partner supported Shelter type (check all that apply) ❑ Evacuation �<General ❑ Medical F- Other General facility notes Shelter Capacity Use the calculations to calculate the capacity for sleeping space. Evacuation L ^ usable sq ft + 20 sq ft/person = f 0 person capacity Total sq feet fZ Post Impact gk � usable sq ft + 40 sq ft/person = �GJ' person capacity Sq feet usable for 1 - -� sleeping spacer r Other usable sq ft + sq ft/person = person capacity ;;?- -Aocry C Use major landmarks (e.g. highways, intersections, rivers, railroad crossings, etc.) that will be easily recognizable in a disaster. Latitude and longitude coordinates can be found at online web sites, using a global positioning system device, or will auto populate when the address is entered into the National Shelter System. Latitude 3y,19?7S6- Longitude _ -77 . ?,?ZIy1 Elevation In storm surge/ ❑ Yes Hurricane category or El No In flood (- Yes year flood VNo evacuation evacuation area plain impact Directions to facility Shelter Facility Survey 1 Rev. 8 -15 -2011 +:. Shelter Facility Survey Point of Contact to Authorize Use of Facility Name ���i S I 'n.l(!fZ l e 1 Title ��uj�+ i (� 1cq_v1C�q�Phone# alo -7yo-210 24 hour# TD_�7 _4+ F1 Fax# Email ee���Y del — �(✓p,(j�(���01� Contact notes Point of'l Contact to Open Facility C- Name (NCkri nz) I Title �l r il,I',hone# 1/0 — %Q8 a7� �IID r Sere it=;�" `� 24 hour# QIO_ )4,7 /_go IFax# Email vi0ACttr,noC )11C 0V, i( Contact notes �� Alternate Point of Contact Name Title Phone # 24 hour # Fax # Email Contact notes Pet Shelter Pet shelter space available on site ❑ Yes answer questions below ❑ No nearest location Separate L] Yes ❑ No Cement or file [:j Yes ❑ No Outdoor space E] Yes ❑ No ventilation system floors with drains to relieve pets Agency that will ��(( Phone # 24 hour # C operate the pet shelter d eY l �t T I f Shelter agreement Yes ❑ No Date signed aI Notes signed Pre -designated shelter ly/ves �� Team name E] No team assigned vv Current facility floor ❑ Yes Location of copies ❑ No plans available International Association of Venue Managers (IAVM) facility ❑ Yes ❑ No Use the Standards for Selection of Hurricane Evacuation Shelters to select hurricane evacuation shelters. In this document, you will find a planning process that involves many factors (e.g. technical information for storm surge and flood mapping). This process requires c lose coordination with local officials for technical information to make decisions about hurricane shelter suitability. Use the Facility Construction section to assist with determining whether this can be a hurricane evacuation shelter. Shelter can be a hurricane evacuation shelter -�n Yes ❑ No Notes 2Icx5sroorls eaA be Invade shelter Facility Survey 2 Rev. 8-15 -2011 American Red Goss Shelter Facility Survey Survey conductors (List all who participated in the survey) Name Title Organization Phone # This facility will be available for This facility is only available for use This facility is not available for use Check one F] This at any time during the year ❑ during the time periods listed below ❑ during the time periods listed below Dates (mm/dd/yyyy) Times (hh:mm) Dates (mm/dd/yyyy) Times (hh:mm) From ❑ AM ❑ PM From ❑ AM ❑ PM To ❑ AM ❑ PM To ❑ AM ❑ PM List any recurring dates that the facility is not available (e.g. every sunday) Areas of the facility that are restricted during use Facility Construction Construction F-] Wood ❑ Masonry/Brick ❑ Pre -fab ❑ Bungalow ❑ Concrete ❑ Metal ❑ Trailer E] Pod material [�j Other # stories/ Notes floors 2 Elevator F"Yes Location ❑ No Notes Open roof -spans (see Standards for Selection of ❑ Yes Length ❑ No Hurricane Evacuation Shelters for current standards) Windows in dYes ❑ No If yes, shatter ❑ Yes [v�rNo If yes, protected ❑ Yes VNo sleep area protected with shutter Fire & AED Safety Some facilities may not meet fire codes based on building capacity. The questions below are a general reference. Contact your local fire department with questions or for more information. Fire alarms & systems Z!orking smoke Inspected fire functional ❑ Functional direct fire Ef (check all that apply) L�� detectors alarm system sprinkler system department alert Comments from fire department ijE J�czr t S o 7"�G l31c� 4 oNl y AED(s) on site [ Yes Location /— I0. '-,v D rVre- E a � //. /iti ,,, �­,pr— ❑ No Shelter Facility Survey 3 Rev. 8 -15 -2011 + � Shelter Facility Survey Facility Inspection Point of Contact If requested, who would inspect this his facility post - impact to determine it is safe to occupy? (� / /,�/ Name G e� R l Iii f� Title ft;4je j1 t4& /`tLinf 3 Phone# 7 �U( �71�0� 24 hour #q /b_q'�/_L4�' Fax# Email l -ee r �JQI �aa4g /ukls,,ie f Contact notes ���YJJJJ LL �I Sanitation, Utilities & Power The recommended ratio for toilet facilities is a minimum of 1 toilet for 20 people. The optimum scenario for showers is 1 shower for every 25 residents. Count all facilities that will be available to shelter residents and staff. Showers available ❑ Yes # of showers E�No Toilets available [Yes # of toilets ❑ No Check all that apply Heating F] Electric L I N Gas atural ❑ propane ❑Fuel Oil Cooling ErElectric ❑ Gas Natural [] Propane Check all that apply Cooking [v]`Electric ❑ Natural Gas ❑ Propane Water 01municipal ❑ Well(s) ❑ Trapped Self- sufficient power ❑ Yes Type [v3 No Note fuel requirements, generator capacity, facility areas supported by generator(s), and other relevant information. Emergency F-1 Yes gNo Notes generator on site Feeding Food Prep (check all that apply) .Warming oven kitchen ❑ Full service ❑ Central kitchen (delivery) Food stock ❑ Yes # meal can ❑ No Refrigeration Yes # units ❑ No stored on site be served units on site Seating Cafeteria C r Snack Other indoor Total estimated seating capacity Bar seatingQ capacity for eating Notes on feeding See accompanying Shelter Facility Survey- Accessibility Instructions. Facility Facility built in 1993 or later, or extensively altered in 1992 or later. ❑ Yes WNo Construction tt 0-5,­1 73rds t 9G7 , iVc.v 20/7 Parking Areas Parking available. ...... — - - -- - -- -------- ................... ............................... ❑ Yes ❑ No Answer below if parking is available Accessible parking dyes F-1 Notes space(s) Van accessible Yes ❑ No Notes parking space(s) Drop -off/ Permanent drop -off area /loading zone with marked access aisle or space available to Loading Area designate as temporary drop -off area /loading zone. [Yes L] No Shelter Facility Survey 4 Rev. 5- 15.2011 +i c- Shelter Facility Survey Sidewalk connects parking area and any drop-off area to at least one facility entrance. ErYes ❑ No ..................................... ............................... .......................................................................... .-............. ..... ... .. ...I...... Route from accessible parking spaces and any drop-off area/loading zone to at least one [ErYes ... .................. ❑ No facility entrance has no steps or curbs without curb cuts. Service restrooms and showers 4r service can be provided In area that can be accessed by .............................................................................-.......................... ............................... --................................_..................._...............................__...... ............................... Where route crosses curb, curb cuts are at least 36" wide. [Yes ............. ❑ No . ... . ........ .................... ..................... ....--.............--.............................................................._....... .... _ ........ _ ............... _ ................................ ... _...................................................................... Automatic doors or doors without knob hardware. ❑ Yes R'No ..........................................-.......... ............................... ---._.._.- ............................................. ............ - Doorways at least 32" wide when door is open. ............. ............................................ ['Yes ❑ No ........... .._...................................._ ......._......................_ ._ 1-- ............................_........._......__......._._.._..._......_._.................................................................................................. Level landings on interior and exterior sides of entry door. _._...._....................... [5Yes ❑ No ............... ........................... ................ ........... .................... .......................................................................... No objects protrude from the side more than four inches into the route to the facility .......- ......................... [✓] Yes ...... ❑ No entrance. (which must be only 32" wide), no part of the route is less than 36" wide. If the main facility entrance does not appear to be accessible, another entry is Route has vertical clearance of at least 80 ". acces-- No ....................._.._..........................................---........................................_..............................._......................................................................................... A sign identifies the location of the accessible entrance. ... . ............................... Yes ❑ No Appropriate grab bars. B Yes ❑ No .......... ........... ........... --- ......................... ......................................... ........................................... .......................... _ .... _._ ....................................... _...._.. ......................... ...................................................... Toilet paper dispenser is within 36" of the rear wall. [5Yes ❑ No .............. ............................... -- .............................. ......................................_._.._..._.............................._...........................-.................... ............................... ................... ................ At least one accessible sink. Yes ❑ No Shelter Facility Survey 5 Rev. 8- 15.2011 Routes to A route without steps is available to access each service delivery area, as well as Service restrooms and showers 4r service can be provided In area that can be accessed by ErYes ❑ No Delivery Areas route with no steps. _ ........... .......................... _.. Using a yard stick held horizontally at your waist level, walk from the facility entrance to each service delivery area, as well as restrooms and showers. Except at doorways ❑ Yes [jNo (which must be only 32" wide), no part of the route is less than 36" wide. Route has vertical clearance of at least 80 ". ❑ Yes No ... ... ............................................................................................................................................................................................................................................................................... No objects protrude from the side more than 4" into the routes to the various service ............................... ❑ Yes MINo delivery areas. ._ ................... _ ......................... _._ ........................... _._........................................................................................... ................ ............................... . _......................... Automatic doors or doors without knob hardware. ❑ Yes [fNo ........... ............................... ............................... .................................. ..._ ..... __........................................................... Doorways at least 32" wide when door is open along routes to each service. E3 Yes ❑ No ....................................... . ..................... . . . . . . ........................ . .................................... . . ........................................ . . . . . . . ................................ . . . . _ . . . . . . . . . . . . . . . . . . . . . . . _ H a service delivery area is accessible only by elevator, there is back -up power for the . . . . . 11 ............. . . . . . . ❑ Yes . . . . . . . . . . . . . ............... [�No elevator(s). 111 .... ........... ......... ... ..... . ....._... .. ......................... ................... Ramps Ramps are at least 36" wide, have handrails on both sides 34 " -38" above the ramp dyes ❑ No surface, and have level landings at least 60" long. If yes, type of ramp ❑ Fixed ❑ Portable ❑ Not provided .. ...................................... .. ........ If ramps are lge t 30 feet, a level landing at least 60" long Is provided every 30 .......... [5Yes __- .......... ❑ No feet. ......... ................ . - -- ............. ..... _ . . ........................................................ . Restrooms Area where person in a wheelchair can turn around (60 -inch diameter circle or T -shape [] Yes ❑ No turn area). t... Doorways at least 32 wide when door is open. ............. . [Yes [] No s IraG Doors without knob hardware ................. ............... ............................... - -- ._..._ ....................... [Yes _ .......... ❑ No . o I n ` Toilet seat is 17 " -19" high. Flush control is automatic or manual control on the open side of the toilet and no higher than 48 r T u Yes ❑ No C .... ........... ......_ ............................................... Toilets centerline Is 16"-18' from the nearest side wall. dYes ❑ No J...... v f Ga ..... ....... .... ..................... _..... _ Stall at least 60" wide and 56' deep (wall- mounted toilet) or 59" deep for (floor mounted [Yes ❑ No U ( toilet) Space at least 9" high is provided beneath the front and one side of the stall. Q Yes ❑ No Appropriate grab bars. B Yes ❑ No .......... ........... ........... --- ......................... ......................................... ........................................... .......................... _ .... _._ ....................................... _...._.. ......................... ...................................................... Toilet paper dispenser is within 36" of the rear wall. [5Yes ❑ No .............. ............................... -- .............................. ......................................_._.._..._.............................._...........................-.................... ............................... ................... ................ At least one accessible sink. Yes ❑ No Shelter Facility Survey 5 Rev. 8- 15.2011 + A-1111 : Shelter Facility Survey Show ers Showers available. It -p" • Fi c /c/ S4 o_,:7e s ❑ Yes ✓["No area ........... ........................._.._ -_ ................... Answer below if showers are available At least one accessible shower stall with appropriate grab bars: ❑ Yes ❑ No Shelter ❑ Stall type ❑ Transfer stall ❑ Roll -in shower ❑ Not provided laundry facilities workers .................... ............................... ._______ ___........................................_............_....................................... Shower seat 17"-19' high. If in transfer stall, seat is on the wall opposite the shower ............................... ❑ Yes ❑ No controls. If in roll -in shower, seat is on wall adjacent to the shower controls. . . . . . . . . . . ........ . . . . . . . . . . . . . . . . . . . . . . . . . . ............................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... . . ............ . . . . . . . . . . . . . . . . . . . . . ..................... . . . . . . ....... ................... . . . . . . . . . . . . . .. .... ......................................... Hand -held shower spray with ability to mount at 48" (typically via a mount that can be . ........................................... ❑ Yes ❑ No adjusted along a fixed vertical bar), or alternatively a fixed shower head at 48 ". . . . . . . .... . ..................... . . . . . . . . . . . . . . . . . . . . . . . . . . .............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cots ❑ Yes # of cots ❑ No available Location Controls do not require tight grasping, pinching or twisting and are mounted 38 "-48" high . . . . . . . . . . . . . . . . . . . . . . . . . ❑ yes . . . . . . . . . . . . . . . . . ........... ❑ No Location and no more than 18" from the front of the shower. ........ ......I... ........... .......... ................ - ... ._.... _.... ........ Eating areas At least some tables have tops 28 " -34" high and space underneath at least 27" high, 30' ✓7Yes L] No Chairs & tables wide and 19" deep. _...._ ......................_........_....................................... ..__ .................. ....._ ......................... - ................... - ......................... . ................... .. ............................ ...... .................... cribs & changing table) available Serving line or counter no higher than 34 ". .._......__..... 0 Yes ..._...._.. ❑ No Assessment Relevant areas of the facility are accessible to people with disabilities without dye ❑ No adjustments. ............... .. ........ . Facility has at least one accessible entrance and one accessible restroom and dyes ❑ No otherwise is capable of being made accessible during a disaster with minor adjustments. ..... ..... .... ... Facility would require extensive adjustments to be accessible during a disaster. Yes ❑ No Adjustments for Accessibility (Identify any adjustments or enhancements that should be made to make the relevant areas of the facility accessible during a disaster) Facilities & Space Isolated care ❑ Yes ❑ No Type ❑ Rooms ❑ Shelter El Separate Shelter ❑ Yes [] No areas of area area facility/area registration area Laundry [-] of Yes g No # of Who can access the Shelter ❑ Shelter ❑ facilities washers dryers laundry facilities workers residents Special conditions or restrictions for laundry Available Materials One cot and two blankets per shelter resident is recommended. Note all available materials for shelter use in the notes section. Cots ❑ Yes # of cots ❑ No available Location Blankets ❑ Yes # of 7L— No Location available blankets Children's supplies (e.g. ❑ Yes ❑ No Chairs & tables ❑ Yes # of # of ❑ No cribs & changing table) available chairs tables Notes Shelter Facility Survey 6 Rev. 8 -15 -2011 + e" Shelter Facility Survey Facility Ownership & Proximity Considerations Does the entity that plans to manage the shelter own the building? ❑ Yes [q No ��° b� {NCC ✓ If no, Is there a current written plan? [✓Yes ❑ No ��aN� CoN �� ................... . .................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ . . . . . . . .................................... Is this facility within five miles of an evacuation route? ❑ Yes . ❑ No vN�S a �cD N H N .......... ........ Is this facility within ten miles of a nuclear power plant? ❑ Yes .................. ❑ No Groups Associated with the Facility & Training Facility staff required when using facility? ❑ Yes ❑ No ......... .................... ..... .. ... -- .11 Paid feeding staff required when using facility? ❑ Yes ❑ No __........._............................................... ................................ - ... ........ ......... _ ........ .......... - .............. ---------- _................. Church auxiliary required when using facility? ❑ Yes ❑ No ....... . ............. . . ................... . . . . . . . . . . . . . . . . . . . . . . . . .................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................... Fire auxiliary required when using facility? ❑ Yes ❑ No . ........................ _... ........................ .. ......................... ............ --- Other required? ❑ Yes ❑ No Other ................. -- ............... ....... ................... .......................................................................................... ............................... _.._....... Will any of the above groups be trained or experienced in Red Cross shelter operations or support? ❑ Yes [:]No If yes, describe capabilities Has the facility been trained in Red Cross sheltering (if not Red Cross managed)? [-]Yes ❑ No If yes, describe capabilities Training requested by facility or group ❑ Yes # of staff to be trained ❑ No ADDITIONAL NOTES & INFORMATION Shelter Facility Survey 7 Rev. 8 -15 -2011 Shelter Facility Survey Chapter Category / Priority of Use: Designated by chapter leadership after the survey is completed This is a riP mary shelter for General Evacuation Shelter cannot be used for General Evacuation (check one) ❑ population ❑ Center (check all that apply) ❑ population ❑ Center This is a priority shelter for the ❑ Hurricane ❑ Earthquake ❑ Large Scale Fire / Flood / following events (check all that apply) Shelter Facility Survey 8 Rev. 8 -15 -2011