Template Field Operations Guide



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Assistance Center Forms


Site Forms

76. Activation Checklist

77. Prospective Site Assessment Worksheet

85. Room Assessment Worksheet

87. Site Determination

88. Assistance Center Facility Agreement



Supply Forms

93. Equipment and Supplies

104. Signs

Workforce Forms

105. ICS 211A – Staff Sign-in Sheet

106. Staffing Determination Tool: Family Assistance Center

108. Position Identification Assignments: Reunification

109. Position Identification Assignments: Family Assistance Center

Safety Forms

110. Safety Walkthrough Checklist



Registration Forms

112. Family/Friend Registration Form

115. Missing Person Form

116. Missing Person Tracking Form

117. Survivor Form

Public Information Forms

118. PIO Cheat Sheet



Child Care Forms

120. Pediatric Safe Area Checklist

121. Childcare Area Sign In/Out Sheet

Minor Reunification Forms

122. Minor Reunification Verification - Adult Form

123. Minor Reunification Verification - Child Form

124. Reunification Completion Checklist



Demobilization Forms

125. Demobilization Checklist

126. Demobilization Procedures

Activation Checklist


  • Based on the incident size, number of victims, and other factors listed in the plan,
    determine the approximate scale of the event:

Incident Type

Date Time

Approximate number of victims

Estimated number of family/friend to arrive at the AC

Estimated incident size (# of days, geographic)


  • Logistics: review site assessment worksheets and select the location of the AC facility

Facility Activation Information

Facility Name

Street Address

City State Zip Code



  • Identify and activate services that will be provided at the AC (check all that apply).




      • Reception/Registration

      • Family Briefings

      • Survivor Information Services

      • Health Services

      • Ante Mortem Interviews

      • Missing Persons Tracking

Support Services:

        • Childcare Services

        • Translation/Interpretation Services

        • First Aid and Behavioral Health/Medical Referral

        • Social Services (see the Social Services That May Be Required document in the Attachments section)




  • Coordinate with partners and local agencies to fill any resource or staff needs.

  • Finance/Administration: identify all staff and volunteers.

  • Logistics: identify and acquire all equipment and supplies needed for the AC Facility.

  • Set up AC Facility.

  • Ensure information technology needs are met and tested

  • Law Enforcement: establish and implement tactical security plan for the facility.

  • Open the AC Facility and coordinate messaging with PIO: location, hours and services.



Prospective Site Assessment Worksheet


Note: If there is an existing building use agreement for sheltering or medical countermeasure dispensing it may be possible to add an addendum specific to assistance centers to the existing agreement instead of creating a new one.

General Site Information:

Review Date

Facility name

Year Built Total Square Footage

Street Address

City State Zip Code

 Non-Profit  Faith-Based  City  State  For Profit  Other

First Contact:

Name Position

Phone Email

Second Contact:

Name Position

Phone Email

What times of the year is the site available:



What supersedes availability for emergency use _____________________________________

Can this site be opened within:  2 hrs  4 hrs  6 hrs  12 hrs  24 hrs Other

Site appropriate for what size event (see the Staffing Determination Tool in the Forms section for guidance):  Small  Medium  Large  Catastrophic

Is this site familiar to the local population:  Yes  No

Current MOU Agreement with this site  Yes  No Details:





Specifications

Y/N

Comments

Available for Use Y/N:

Number of Rooms




# rooms:




Capacity of Rooms *



(See Room Assessment Worksheet for more details on each room)





Capacity of Room:
Capacity of Room:
Capacity of Room:
Capacity of Room:
Capacity of Room:
Capacity of Room:
Capacity of Room:
Capacity of Room:
Capacity of Room:
Capacity of Room:
Capacity of Room:




Equipment Supply Area




Dimensions: __________X___________=____________ ft2
Capacity of Room:




Ability to lock the site




Describe:




Loading Docks




# of Bays: ____________ Forklift on site Y/N: __________
Operator Available Y/N:_____________________________
Electrical Power Available Y/N: Explain: ________________
Material Handling Equipment Y/N: ____________________




Number of Toilets




# of Men’s_____________ # of Women’s: ______________
# of Family/Unisex: ________ # of ADA Accessible: ______




Baby Changing Areas




# of sites: ________________________________________
Where located: ____________________________________




Food preparation and consumption facilities




Capacity of food prep areas: __________________________
Capacity of Food Consumption area (for staff and families): _________________________________________________




Type of Food Preparation Areas




 Full Commercial  Warming  Partial
 Walk-in refrigerator/Freezer




Refrigeration




Size: ___________________ Type: ____________________
Temp Controlled Y/N: ______________________________




Accessibility:

Specifications

Y/N

Comments

Available for use: Y/N

Primary Parking Lot



# of spaces for staff: ________________________________


# of spaces for clients:_______________________________
Cost of Parking per car______________________________
Validation Available? Y/N _____________ Cost:__________
Valet Available? Y/N _______________________________
Is Parking Secured? Y/N ____________________________
Describe:






Secondary Parking Lot



# of spaces:_______________________________________


Cost per car ______________________________________
Is Parking Secured Y/N _____________________________




Adequate Road Access



Describe: ________________________________________






ADA Accessible



# Stairs: ___________ ADA adaptable Y/N: _________


ADA Compliant Y/N: ______________________________

(Refer to ADA checklist for Emergency Shelters)







Public Transportation



Stop Name/Line: __________________________________


Stop Name/Line: __________________________________




Proximity to Local Hospitals



Hospital name: ____________________________________


# Miles away: _____________________________________




Security



# of Officers _____________________________________


Security System Provider: ____________________________
Surveillance Cameras on site: Y/N _____________________
Real time or remote monitoring _______________________




Supplies/IT/Utilities:

Specifications

Y/N

Comments

Available for use: Y/N

Tables



# on site: ________________________________________


Size: ____________________________________________




Chairs




# on site:




Beds




# Adult beds/cots on site: ___________________________
# Pediatric beds/cribs on site:_________________________




Childcare equipment




Describe:




Temporary Partitions




# on site:_________________________________________
Describe:




Computers




# on site:




FAX machines




# on site:




Copiers




# on site:




Telephones




# on site:




Televisions




# on site:




Scanners




# on site:




Shredders




# on site:




File Storage Container




# on site:




Podium




# on site:




Audio/Visual Equipment




# on site: ________________________________________
Description: ______________________________________




Industrial Fans




# on site:




Janitorial Services



# of trash cans on site:______________________________


Describe removal methods: __________________________
Sharps Container Y/N and #: ________________________




Fire Safety System




 Sprinklers  Alarms  Smoke Detectors
Carbon Monoxide Detector
Date of last test/inspection: __________________________
# of Extinguishers: _________________________________




Radio




# and Type: ______________________________________
Known interference or Shielding Y/N: __________________




Internet




Service provider:___________________________________
Type of Internet:  Wi-Fi  Hardwire  Satellite
Known interference or Shielding Y/N: __________________




Cable TV




Service provider:




Phone-

Include Cell Phones






Service provider: ___________________________________
Known interference or coverage gaps Y/N: ______________




Electricity




Service provider:

Outlets per room/capacity:






Overhead Lighting




Sufficient for AC Operation Y/N:




Generator




Sufficient for AC Operation Y/N: ____________________
Transfer switch for trailer mounted generator Y/N: ________________________________________________




Water




Service provider: ___________________________________
 Hot  Cold  Potable




Heat/AC




Heat Y/N: _________________ AC Y/N: ______________
Type :  Electric  Gas




Gas




Services Provider:




Transportation vehicles




Describe:





Facility Documents

Services the facility will continue to provide:

Service

Y/N

Comments/Contact Information

Janitorial







Food Preparation / Cleaning







Restroom Maintenance







Facility Maintenance







Security







Necessary documents to be attached:

Document

Y/N

Comments

MOU or
contract for the site







Fire and Capacity Regulations







Evacuation Plan of site







Floor Plan of site







Photographs of Site

(including Satellite images)









Maps







Recommended Functional Areas Checklist

Check the box for each functional area that can be accommodated by prospective site

Main Service Areas


  • Reception and Registration

  • Family Interview/Notification Rooms

      • Behavioral Health Services

    • Private Consultation Areas

    • Staff Meeting Room

    • Staff Break Room

  • Missing Persons Call Center (could be off site)

  • Waiting Area

  • Family briefing area (for families and responders to gather and brief)

  • Television room (located away from the waiting room)

  • Computer/Phone Bank

  • Childcare Area

  • Food Preparations Area

  • Dining Area

  • Family Meeting/Gathering area (for families to meet one another)

  • Media Station (secured location far enough away from the FAC but sufficient for briefings)

  • Memorial area (wall, room, table)

  • Incident site map/diagram area

  • Secondary Services area (social services area)

Back Office Areas


  • Staff Check-in

  • Staff Work Area

  • Command Staff Area

  • Staff Conference Rooms

  • Staff Break Room



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