Passed, Adopted and Approved this (xx) day of (Month), 20(xx); Central City Clerk; Liberty County Clerk; Central City Council members present & voting; Liberty County Board of Supervisors present & voting; Mayor & Chairman each with 7 Aye and 7 Nay
Figure 7.1. Resolution/Proclamation Passed, Adopted, and Approved Signature Form
 
The following three tables were developed with reference to the Center for Disease Control and Prevention (CDC) – Interim Occupational Health and Safety Survey Tool – Shelters form.
Agency/Organization Doing the Assessment 
Group #  
Surveyor Name 
Date of Assessment (dd/mm/yyyy) 

Table AA.11. Interim Occupational Health and Safety Survey Tool – Shelters – Surveying Agency Data

 
Location Name 
Street Address 
City 
State 
Zip 
Location Description 
Latitude/Longitude  
Number of Employees 
Contact 
Phone (work) 
Phone (cell) 
Email 

Table AA.12. Interim Occupational Health and Safety Survey Tool – Shelters – Facility Name and Spatial Data

Area

Assessment Item

Acceptable (Yes)

Not Acceptable (No)

Comment

01

Are staffing levels adequate for providing shelter services?   

02

Is a program in place to provide and monitor employee Health and Safety?   

03

Is an occupational health and safety training provided to all new shelter employees and volunteers?   

04

Is there a record keeping system in place to collect worker illness and injury data?  Method:

05

Are Standard Precautions included in orientation?   

06

Are Personal Protective Equipment (PPE) requirements included in the orientation?   

07

Are supplies of worker PPE adequate?  Inadequate:

08

Are procedures in place for:

  1. Infectious waste handling?
  2. Isolation of potentially infectious patients?
  3. Handling of laundry?
  4. Cleaning the facility?
   

09

Are there Infection Control issues at this site? (If yes, describe in the comment box)   

10

Is there a safe system for providing food for workers?   

11

Is there a system for providing rest breaks for the workers?   

12

Are adequate hand-washing facilities provided?   

13

Is there a main safety and health concern among workers at this site? (If yes, describe in the comment box.)   

14

Is information needed about any specific occupational risk or exposures? (If yes, describe in the comment box.)   

Table AA.13. Interim Occupational Health and Safety Survey Tool – Shelters – Assessment Items

AGREEMENT TO PERMIT THE USE OF A FACILITY AS A RED CROSS EMERGENCY SHELTER

Effective Date: Upon execution.

Expiration Date: None. Owner or Red Cross may terminate the agreement upon 30 days’ notice.

Owner: [legal name of Owner of facility]

Owner’s 24 Hour Point of Contact (name and cell phone number)

Primary:

Alternate:

Owner’s Address for Legal Notices:

Red Cross: The American National Red Cross, a not-for-profit corporation under the laws of the United States.

Red Cross 24 Hour Point of Contact

Primary: Disaster Supervisor On-Call at 702-591-4025 (cell)

Alternate: Director of Emergency Services at 702-591-4022 (cell)

Red Cross Address for Legal Notices: The American National Red Cross, Southern Nevada Chapter, 1771 E Flamingo #206B, Las Vegas, NV 89119 with a copy to The American National Red Cross, Office of the General Counsel, 2025 E Street, N.W., Washington, D.C. 20006 and with a copy to The American National Red Cross, Disaster Operations, 2025 E Street, N.W., Washington, D.C. 20006;

Red Cross Address for Invoices: Southern Nevada Chapter, 1771 E Flamingo #206B, Las Vegas, NV 89119, with a copy to: The American National Red Cross, Facilities Associate - Field Logistics, Disaster Response, 2025 E Street, Washington, D.C. 20006.

Name and Address of Shelter:

OWNER: RED CROSS:
 The American National Red Cross
  
By:By:
Name: Name:
Title:Title:
Office Phone: Office Phone:
Cell Phone: Cell Phone:
Email: Email:
Date: Date:
 
TERMS AND CONDITIONS

This Agreement is made for the temporary use of a facility designated by Owner for use as a public shelter during a declared or undeclared natural disaster or other condition or event requiring the activation of the disaster relief functions of The American National Red Cross (referred to as an “Emergency”). The parties desire to reach an understanding that will result in providing the facility owned by the Owner to the Red Cross to operate an emergency shelter for the benefit of Owner’s community.

  1. Owner’s Responsibilities.
    1. Owner has identified the facility, and Red Cross has determined that the facility may be suitable for use as a public shelter, or staging area, or for other purposes in connection with disaster relief operations. (The facility is referred to as the “Shelter”). Upon request by the Red Cross (which may be made orally or in writing) Owner will make the facility available to Red Cross for use as a Shelter.
    2. Owner will appoint a person to coordinate the Owner’s activities (This individual is referred to as the Owner’s “Facility Coordinator”). The Facility Coordinator will coordinate the use of the Shelter with the Red Cross’s designated official. (The Red Cross official is referred to as the “Shelter Manager”). The Facility Coordinator and the Shelter Manager will collaborate to resolve questions regarding Shelter operations. The Facility Coordinator and the Shelter Manager will jointly conduct a pre-inspection survey of the Shelter before it is turned over to the Red Cross. The pre-inspection survey, attached as Exhibit A, will be used to identify and record any existing damage or conditions. The Facility Coordinator will secure all equipment that is not supposed to be used by the Red Cross in the operation of the Shelter. 
    3. The Facility Coordinator will, on request and if feasible, designate a “Food¬service Manager” to establish a feeding schedule and determine foodservice inventory and supply needs. The Facility Coordinator also will, on request and if feasible, designate a Facility Custodian, to establish and direct the sanitation inventory and supply needs. The Shelter Manager and the Facility Coordinator will jointly coordinate a work schedule for any personnel who are not Red Cross employees, volunteers, or contractors. If it is not feasible for one or both of a Foodservice Manager or a Facility Custodian to be designated by the Facility Coordinator, the Facility Coordinator will inform the Shelter Manager, who may obtain such services by contract.
    4. At the direction of and in cooperation with the Shelter Manager, the Food¬service Manager will provide the food and supplies needed for meals at the Shelter site. If, in the opinion of the Shelter Manager, additional food or supplies are needed, the Shelter Manager will coordinate the procurement of the additional food or supplies. Red Cross will pay or reimburse Owner for all food and supplies as approved by the Shelter Manager and used in the course of operating the Shelter.
    5. The Facility Custodian will provide sanitation services and supplies for custodial care at the Shelter as directed by the Shelter Manager. The Facility Coordinator or Facility Custodian will order and provide all additional sanitation and custodial supplies and services as shall be determined by the Shelter Manager. Red Cross will pay or reimburse Owner for all sanitation supplies as approved by the Shelter Manager and used in the course of operating the Shelter.
    6. Red Cross is not responsible for police or public safety at the Shelter. Any private security services that are to be the responsibility of Red Cross must be arranged under a separate agreement. Shelter population shall be exclusively the role of Red Cross. Owner shall not distribute or reveal any information concerning occupants of a Shelter without the express written consent of the Shelter Manager. No press releases or other information shall be disseminated without the express written consent of the Shelter Manager. Owner will refer all media questions related to the Shelter to the Shelter Manager.
    7. Within thirty (30) days after the close of a Shelter, the Facilities Coordinator shall submit to the Red Cross all invoices to the address above. Invoice backup must include a list of the Shelter operations personnel and hours worked at the Shelter, and details on any materials or goods used or consumed.
  2. Red Cross’s Obligations.
    1. The Red Cross Shelter Manager has primary responsibility for the operation of the Shelter. Red Cross will provide additional Red Cross staff and volunteers to carry out the activities of the Shelter. Red Cross will post signs identifying the Shelter. Red Cross will remove all Red Cross signs when the Shelter is closed. Red Cross and all of its agents, and employees, and volunteers will exercise reasonable care in the operation of any Shelter.
    2. Storm damage or other damage caused by the Emergency is not the responsibility of Red Cross. Red Cross reimburses personnel costs at actual current per hour straight time rate for instruction, custodial, maintenance, and food service. Red Cross will reimburse Owner for the reasonable actual out-of-pocket costs and expenses for operational expenses, including the replacement of food, supplies, equipment. Property damaged, lost or stolen due to the negligence of Red Cross will be compensated based on depreciated actual cash value. Reimbursement for any extraordinary or capital expenses (including without limitation painting, carpeting, wiring, and structural work) will be limited to replacement at actual cash value of the property. In such cases, Red Cross will select from among bids from at least three reputable contractors.
    3. Red Cross will notify the Owner or Facilities Coordinator of the closing schedule for the Shelter. After the Shelter has been closed, the Facility Coordinator and the Shelter Manager will conduct a post-disaster facilities survey to ensure that the Shelter is returned to the Owner in the same condition as it was when it was opened, ordinary wear and tear excepted. The form to be used for this post-operation survey is Form 6556 (Release of Facility) attached as Exhibit B.
Shelter Facility Survey
Shelter Facility Survey American Red Cross Form 6564 (http://nehacert.org/EHTER/EHTER_Resources/Shelters/ARC_Shelter_Survey.pdf)
 
Refer to the content within the IG/SM for the alt text description of this image.
American Red Cross Release of Facility Image Description

American Red Cross

Release of Facility

This is to certify that the (Blank Line for Name, Blank Line for Address, Blank Line for Telephone) controlled, owned or operated by (Blank Line) and used temporarily by the American Red Cross, DR # (Blank Line for #), (Blank Line for Name) as an emergency disaster facility from (Blank Line for from date) to (Blank Line for to date), is hereby returned by the American Red Cross to (Blank Line for company/organization) in a satisfactory condition, less the following deficiencies:

(Blank space to fill in any deficiencies)

Signature of Owner/Operator, Printed Name & Title, Date

Signature of American Red Cross Representative, Printed Name & Title, Date

American Red Cross Form 6556 (March 2006)