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19 <br /> American <br /> Red Cross Red Cross On-Site Shelter Survey Form <br /> The Red Cross surveyor records the information on this form. (Instructions and definitions below form.) <br /> Site Name: Address: <br /> Red Cross representative: Red Cross contact info: <br /> Person completing form: Date completed: <br /> Check and describe all modifications that may be required to use this site as a shelter. Refer to the last <br /> page for definitions. <br /> ❑ Accessible Parking' ❑ Accessible Sidewalk or Walkway2 <br /> ❑ Accessible Entrance3 ❑ Accessible Route to Service Areas4 <br /> ❑ Accessible Toilets5 ❑ Distraction Reduced Area6 <br /> ❑ Accessible Sinks' ❑ Accessible Shower Facilities$ <br /> ❑ Power Supply Access9 ❑ Refrigeration10 <br /> Other Needs and Details: <br /> AREA INFORMATION: <br /> Most facilities have multiple, separate spaces available that can be used. Record details about each area. <br /> Area Name": Length: Width: Sq Ft of Area: <br /> Intended Uses: ❑ Dormitory ❑ Feeding ❑ Safest Refuge12 ❑ Reception ❑ Client Meeting Areas ❑ Pet Shelter <br /> ❑ Administration/Storage ❑ Client Isolation Area <br /> Windows in the Area: ❑ Y ❑ N Long or Open Roof Spans in Dormitory: ❑ Y ❑ N <br /> If any of the items below are accessible to multiple areas,please split them up amongst the areas. <br /> Total Number of toilets: Number of Accessible toilets: <br /> Total Number of showers: Number of Accessible showers: <br /> Total Number of bathroom sinks: Number of Accessible bathroom sinks: <br /> To Be Used by Red Cross Surveyor <br /> MC Red Cross On-Site Shelter Survey Form V.1.0 2024-08-26 <br />