Survey Conductors (List all who participated in the survey) Name Title Organization Phone # LIMITATIONS OF FACILITY USE Check one This facility will be available for This facility is only available for use This facility is not available for use use at any time during the year during the time periods listed below during the time periods listed below (mm/dd/yyyy) (hh:mm) Dates Times (mm/dd/yyyy) Times (hh:mm) From AM PM AM PM From 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 & SAFETY Facility Construction Masonry/Brick Pre-fab Bungalow Concrete Metal Trailer Pod Wood Construction material # stories/ floors Elevator Yes No Location 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 Working Inspected fire sprinkler system Fire alarms & systems smoke system (check all that apply) detectors Functional direct fire Comments from Functional department alert AED(s) on site
Survey Conductors (List all who participated in the survey) Name Title Organization Phone # LIMITATIONS OF FACILITY USE Check one This facility will be available for use at any time during the year This facility is only available for use during the time periods listed below This facility is not available for use during the time periods listed below Dates (mm/dd/yyyy) Times (hh:mm) (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 Wood FACILITY CONSTRUCTION & SAFETY Masonry/Brick Pre-fab Bungalow Concrete Metal Trailer Pod Construction material # stories/ floors Elevator Yes Location No 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 (check all that apply) Comments from fire Working smoke detectors Inspected fire system Functional sprinkler system Functional direct fire department alert AED(s) on site
Shelter%20Facility%20Survey.docx