To Be Used by Red Cross Surveyor
MC Red Cross On-Site Shelter Survey Form V.1.0 2024-08-26 Red Cross On-Site Shelter Survey Form
The Red Cross surveyor records the information on this form. (Instructions and definitions below form.) Site Name: Address:
Red Cross representative: Red Cross contact info:
Person completing form: Date completed:
Check and describe all modifications that may be required to use this site as a shelter. Refer to the last page for definitions.
☐ Accessible Parking1 ☐ Accessible Sidewalk or Walkway2 ☐ Accessible Entrance3 ☐ Accessible Route to Service Areas4 ☐ Accessible Toilets5 ☐ Distraction Reduced Area6
☐ Accessible Sinks7 ☐ Accessible Shower Facilities8
☐ Power Supply Access9
Other Needs and Details:
☐ Refrigeration10
AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name11: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge12 ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐ Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
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Modern facility with heat & A/C throughout. No showers on site.
El Palo Alto West
50'
32'
1,600
4 men & 7 women (11 tot)
1M & 1 W (2 tot)
0 0
2M & 2 W (4 tot)
1M & 1W (2 tot)
To Be Used by Red Cross Surveyor
MC Red Cross On-Site Shelter Survey Form V.1.0 2024-08-26 AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐ Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐ Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
Please print additional pages for each area being surveyed. ■
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El Palo Alto East & Kitchen
50 32
1,548
0 0
0 0
1 1
Matadero
37 21
777
0 0
0 0
2 1
To Be Used by Red Cross Surveyor
MC Red Cross On-Site Shelter Survey Form V.1.0 2024-08-26 AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
Please print additional pages for each area being surveyed. ■
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Oak
45 23
1,035
1 0
0 0
1 1
Teen Center
45 32
1,440
0 0
0 0
0 0
To Be Used by Red Cross Surveyor
MC Red Cross On-Site Shelter Survey Form V.1.0 2024-08-26 AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐ Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐ Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
Please print additional pages for each area being surveyed. ■
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Adobe North and South
43 36
1,548
0 0
0 0
1 1
0 To Be Used by Red Cross Surveyor
MC Red Cross On-Site Shelter Survey Form V.1.0 2024-08-26 AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐ Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐ Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
Please print additional pages for each area being surveyed.
To Be Used by Red Cross Surveyor
MC Red Cross On-Site Shelter Survey Form V.1.0 2024-08-26 AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐ Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐ Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
Please print additional pages for each area being surveyed. 0 To Be Used by Red Cross Surveyor
MC Red Cross On-Site Shelter Survey Form V.1.0 2024-08-26 AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
AREA INFORMATION:
Most facilities have multiple, separate spaces available that can be used. Record details about each area.
Area Name: Length: Width: Sq Ft of Area:
Intended Uses: ☐ Dormitory ☐ Feeding ☐ Safest Refuge ☐ Reception ☐ Client Meeting Areas ☐ Pet Shelter ☐Administration/Storage ☐ Client Isolation Area
Windows in the Area: ☐ Y ☐ N Long or Open Roof Spans in Dormitory: ☐ Y ☐ N If any of the items below are accessible to multiple areas, please split them up amongst the areas.
Total Number of toilets: Number of Accessible toilets:
Total Number of showers: Number of Accessible showers:
Total Number of bathroom sinks: Number of Accessible bathroom sinks:
Please print additional pages for each area being surveyed.
To Be Used by Red Cross Surveyor
MC Red Cross On-Site Shelter Survey Form V.1.0 2024-06
INSTRUCTIONS
This PDF form provides a paper-based method for the Red Cross to capture necessary shelter survey information when not making direct electronic entry into the National Shelter System (NSS). Once information is recorded on this worksheet, a qualified Red Cross worker enters it into the National Shelter System.
Use this form in conjunction with the Shelter Facility Owner Pre-Survey Form, completed by the facility owner or their representative prior to Red Cross scheduling the survey.
The identified Red Cross relationship manager may send the Shelter Facility Owner Pre-Survey Form to the facility owner or their representative by email with the below language:
Subject: Red Cross shelter survey
Body: <Greetings>
Thank you for agreeing to have your site identified as a potential disaster shelter. Included with this email is a fillable PDF that Red Cross would like for you to fill out. Once completed, please email it back to <insert name and email address of Red Cross POC>. Our team will review the information and then schedule a time for Red Cross to visit in-person and collect additional information and photographs. Either myself or one of my colleagues will be contacting you to schedule a time for us to complete the survey. All of these details will then be recorded in the National Shelter System which disaster managers use when considering potential shelters and their suitability for particular emergencies. When a disaster occurs and your ownership is supportive of the Red Cross using your facility, we will work with your representative to complete a facility use agreement and opening inspection form.
<Insert the language in this paragraph when the facility may serve as a hurricane evacuation shelter or delete this section if the site will never be considered during a hurricane evacuation .> As the facility may be opened to serve clients during hurricane evacuations, we would like for you to advise if the site has hurricane safe windows and if the facility has a wind load certification. You can include those details in the email when you return the completed PDF.>
I look forward to answering any questions you have or that arise as you complete this form.
Thank you,
<Name>
<Signature Line>
When completing the shelter survey and site visit, photographs, diagrams and floor plans of various entrances and areas of the shelter may be captured and uploaded into the NSS.
Refer to the final page for definitions and explanation associated with the survey form.
Contact [email protected] with any questions.
To Be Used by Red Cross Surveyor
MC Red Cross On-Site Shelter Survey Form V.1.0 2024-08-26
DEFINITIONS
1 Accessible Parking - The parking space surface appears level and is marked with an accessibility symbol. It is adjacent to an accessible walkway, is at least 96-inches wide and there is at least 98-inches of overhead clearance. 2 Accessible Sidewalk or Walkway - At least 36-inches wide, level surface without hazards on the route or overhead that does not require any steps or curb to the walkway. 3 Accessible Entrance - Entrance connected to an accessible route with a 32-inch-wide passage when the door is open. Door hardware is usable with one hand (lever, pull). 4 Accessible Route to Service Areas - Hallways and corridors at least 36-inches wide with level surface, and no hazards on the route or overhead to all service areas. Elevator access is available when above and below ground. 5 Accessible Toilets - Accessible entrance to the toilet area. The stall must be at least 60-inch wide and 59-inch deep with a door that swings out from the stall, grab bars, and toilet seat 17 to 19 inches above the floor. 6 Distraction Reduced Area - Separate area from main sleeping and service areas with space for physical distancing and low lighting.
7 Accessible Sinks - Sinks and countertops no more than 34-inches above the floor, with mirrors no more than 40 inches above the floor. There must be an open space below the sink for knee clearance at least 27-inches high and 8-inches deep
8 Accessible Shower Facilities - Entrance to shower allows roll-in, is at least 30-inches wide and 60-inches deep, with grab bars and a seat.
9 Power Supply Access Area - Backup source of power is available for clients with life-saving equipment. 10 Refrigeration - Facility has refrigerator available to store life-saving medication for clients. 11 Area Name – The surveyor should record the name used by the facility (i.e.: East Gymnasium, Cafeteria Hall, Conference Room 3, etc.)
12 Safest Refuge Area – The designated safest area for the population to take temporary refuge during external threats such as gale force winds or tornado. Identify an interior, enclosed hallway or room which does not have windows or a wide roof span.