Shelter Facility SurveyBASIC SHELTER INFORMATIONRed CrossSite Name/School DistrictNSS ID#DateBuilding #Name of buildingofShelter addressTown/CityCounty/ParishStateMailing Address (if different) FEMADHSTSASBCRed Cross managedRed Cross partnerRed Cross supportedIndependentEvacuationGeneralMedicalShelter Capacity (See Surveyor Instructions #1)Total sq feetSq feet usable for sleeping spaceOtherOtherEvacuationPost ImpactOtherusable sq ft ÷ 20 sq ft/person = usable sq ft ÷ 40 sq ft/person = usable sq ft ÷ sq ft/person = person capacityperson capacityperson capacityShelter Capacity Phone #WebsiteFax #
Shelter Facility Survey1
General facility notesAgency operating shelter (check one)Shelter agency type (check one)Shelter type (check all that apply)Geographic InformationLatitudeLongitudeElevationUse 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. NoNoYes Hurricane category or evacuation areaYesIn storm surge/evacuationIn flood plainyear flood impactDirections to facility Zip CodeTown/CityCounty/ParishStateZip CodeUse the calculations to calculate the capacity for sleeping space.
Rev. 8-15-2011
Shelter Facility Survey
Shelter Facility Survey2
Pet ShelterNonearest locationanswer questions belowNoNoCement or tile floors with drainsNoOutdoor space to relieve petsAgency that will operate the pet shelter24 hour #Contact notesAlternate Point of ContactNameTitle24 hour #EmailFax #Alternate Point of ContactPoint of Contact to Open FacilityNameTitle24 hour #EmailContact notesFax #YesYesYesYesPet shelter space available on siteSeparate ventilation system Point of Contact to Authorize Use of FacilityNameTitlePhone #24 hour #EmailContact notesFax # ADDITIONAL INFORMATIONNoDate signedNotesNoPre-designated shelter team assignedTeam nameNoCurrent facility floor plans availableLocation of copiesYesYesYesShelter agreement signedNoYesInternational Association of Venue Managers (IAVM) facilityNoYesShelter can be a hurricane evacuation shelterNotes Phone #Phone #Phone #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 close coordination with local officials for 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.Rev. 8-15-2011 Survey Conductors (List all who participated in the survey)Name Title Organization Phone # Shelter Facility Survey3
LIMITATIONS OF FACILITY USECheck oneThis facility will be available for use at any time during the yearThis facility is only available for use during the time periods listed belowThis facility is not available for use during the time periods listed belowDates (mm/dd/yyyy)Times (hh:mm)FromAMPMAMPMDates (mm/dd/yyyy)Times (hh:mm)AMPMAMPMFromToToList any recurring dates that the facility is not available (e.g. every sunday)Areas of the facility that are restricted during use Shelter Facility Survey
FACILITY CONSTRUCTION & SAFETYFacility ConstructionWood Construction materialMasonry/BrickPre-fabBungalowConcreteMetalTrailerPod# stories/floorsNotesNotesNoElevatorLocationYesNoOpen roof-spans (see Standards for Selection of Hurricane Evacuation Shelters for current standards) LengthYesNoWindows in sleep areaYesNoIf yes, shatter protectedYesNoIf yes, protected with shutterYesOther Fire & AED SafetyFire alarms & systems (check all that apply)Working smoke detectorsInspected fire alarm systemFunctional sprinkler systemFunctional direct fire department alertComments from fire departmentAED(s) on siteNoYesLocationSome 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.Rev. 8-15-2011 Shelter Facility Survey
Shelter Facility Survey4
Facility Inspection Point of ContactIf requested, who would inspect this facility post-impact to determine it is safe to occupy?NameTitle24 hour #EmailContact notesFax #Sanitation, Utilities & PowerSANITATION, FEEDING & UTILITIESNatural GasHeating ElectricPropaneFuel OilNatural GasCoolingElectricPropaneNoShowers available# of showersYesNoToilets availableYes# of toiletsNoSelf-sufficient powerYesTypeEmergency generator on siteNoYesNotesCheck all that applyCheck all that applyNatural GasCooking ElectricPropaneWell(s)Water MunicipalTrappedTotal estimated seating capacity for eatingFeedingFood Prep (check all that apply)Warming oven kitchenFull serviceCentral kitchen (delivery)Food stock stored on siteNoRefrigeration units on siteYesNoYes# meal can be served# unitsSeating capacityCafeteriaSnack BarOther indoor seatingNotes on feeding Phone #
ACCESSIBILITYFacility ConstructionFacility built in 1993 or later, or extensively altered in 1992 or later.Parking AreasNoAccessible parking space(s)YesParking available.NotesNoVan accessible parking space(s)YesNotesSee accompanying Shelter Facility Survey-Accessibility Instructions.Answer below if parking is availableDrop-off/Loading AreaPermanent drop-off area/loading zone with marked access aisle or space available to designate as temporary drop-off area/loading zone.NoYesYesNoNoYes 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.Note fuel requirements, generator capacity, facility areas supported by generator(s), and other relevant information.
Rev. 8-15-2011
Shelter Facility Survey
Shelter Facility Survey5
Facility EntranceRoutes to Service Delivery AreasSidewalk connects parking area and any drop-off area to at least one facility entrance.Route from accessible parking spaces and any drop-off area/loading zone to at least one facility entrance has no steps or curbs without curb cuts.Where route crosses curb, curb cuts are at least 36” wide.Automatic doors or doors without knob hardware.Doorways at least 32” wide when door is open.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 (which must be only 32” wide), no part of the route is less than 36” wide.Level landings on interior and exterior sides of entry door.No objects protrude from the side more than four inches into the route to the facility entrance.No objects protrude from the side more than 4” into the routes to the various service delivery areas.If the main facility entrance does not appear to be accessible, another entry is accessible.A sign identifies the location of the accessible entrance.A route without steps is available to access each service delivery area, as well as restrooms and showers or service can be provided in area that can be accessed by route with no steps.Automatic doors or doors without knob hardware.Route has vertical clearance of at least 80”.Doorways at least 32” wide when door is open along routes to each service.If a service delivery area is accessible only by elevator, there is back-up power for the elevator(s).RampsIf yes, type of rampRamps are at least 36” wide, have handrails on both sides 34”-38” above the ramp surface, and have level landings at least 60” long.If ramps are longer than 30 feet, a level landing at least 60" long is provided every 30 feet.FixedPortableNot providedRestroomsToilet seat is 17"-19" high. Flush control is automatic or manual control on the open side of the toilet and no higher than 48".Space at least 9" high is provided beneath the front and one side of the stall.Stall at least 60" wide and 56" deep (wall-mounted toilet) or 59" deep for (floor mounted toilet).Toilet's centerline is 16"-18" from the nearest side wall.Area where person in a wheelchair can turn around (60-inch diameter circle or T-shape turn area).Doorways at least 32" wide when door is open.Doors without knob hardware.Appropriate grab bars.Toilet paper dispenser is within 36" of the rear wall.At least one accessible sink.
NoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesYesNoNoYesNoYesNoYes NoYes
Rev. 8-15-2011
Shelter Facility Survey
Shelter Facility Survey6
ShowersRoll-in showerTransfer stallStall typeAssessmentAdjustments for Accessibility (Identify any adjustments or enhancements that should be made to make the relevant areas of the facility accessible during a disaster) Showers available.At least one accessible shower stall with appropriate grab bars.Shower seat 17"-19" high. If in transfer stall, seat is on the wall opposite the shower 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 adjusted along a fixed vertical bar), or alternatively a fixed shower head at 48".Controls do not require tight grasping, pinching or twisting and are mounted 38"-48" high and no more than 18" from the front of the shower.Answer below if showers are availableFacility has at least one accessible entrance and one accessible restroom, and otherwise is capable of being made accessible during a disaster with minor adjustments.Facility would require extensive adjustments to be accessible during a disaster.Relevant areas of the facility are accessible to people with disabilities without adjustments.Not providedEating areasAt least some tables have tops 28"-34" high and space underneath at least 27" high, 30" wide and 19" deep.Serving line or counter no higher than 34".OTHER CONSIDERATIONSSpecial conditions or restrictions for laundryIsolated care areas YesLaundry facilitiesNoYes# of washers# of dryersWho can access the laundry facilitiesShelter residentsShelter workersAdditional Facilities & SpaceShelter areaType of area RoomsSeparate facility/areaShelter areaNoYesNoAvailable Materials Cots availableNoYes# of cotsLocationLocationBlankets availableNoYes# of blanketsNotes NoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYes
One cot and two blankets per shelter resident is recommended. Note all available materials for shelter use in the notes section.Chairs & tables available NoYes# of chairs# of tablesChildren's supplies (e.g.cribs & changing table)NoYesRev. 8-15-2011 Shelter Facility Survey
Shelter Facility Survey7
Facility Ownership & Proximity ConsiderationsDoes the entity that plans to manage the shelter own the building? If no, is there a current written plan?NoYesIs this facility within five miles of an evacuation route?Is this facility within ten miles of a nuclear power plant? Groups Associated with the Facility & TrainingFacility staff required when using facility? Paid feeding staff required when using facility? Church auxiliary required when using facility? Fire auxiliary required when using facility? Other required?Will any of the above groups be trained or experienced in Red Cross shelter operations or support? If yes, describe capabilitiesHas the facility been trained in Red Cross sheltering (if not Red Cross managed)?If yes, describe capabilitiesTraining requested by facility or groupADDITIONAL NOTES & INFORMATION NoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesOther# of staff to be trained Rev. 8-15-2011
Shelter Facility Survey
Shelter Facility Survey8Chapter Category / Priority of Use: Designated by chapter leadership after the survey is completed.OFFICE USE ONLY (Do not fill out box during survey)This is a primary shelter for (check one) Evacuation CenterGeneral populationShelter cannot be used for (check all that apply)Evacuation CenterGeneral populationThis is a priority shelter for the following events (check all that apply)EarthquakeHurricaneLarge Scale Fire / Flood / ADDITIONAL NOTES & INFORMATION, continued
Rev. 8-15-2011