St. Clair County Facility Evaluation Form

Facility Identification
City/Twp: 
Facility Name: 
Address: 
Parcel ID:    Parcel Search  
Phone:      Ext:    
Fax:     TTY: 
E-Mail: 
 
Facility Emergency Contact
Contact 1 Name: 
Phone:  Ext:            
Cell:  Pager: 
Contact 2 Name: 
Phone:  Ext: 
Cell:  Pager: 
Contact 3 Name: 
Phone:  Ext: 
Cell:  Pager: 
 
Facility Description
Heating System  
Is there air conditioning  
Generators   KW/hr 
If yes,
Power
Entire Building
Lights
Heat
Kitchen
Open Space / Areas
(areas that could be used for additional community sheltering)
Number of rooms
Estimated capacity
Would your facility be willing to shelter outside people?   If yes, how many
Shower   Number of showers
Restrooms Women   Nbr of restrooms
Men   Nbr of restrooms
Unisex/Family   Nbr of restrooms
Phone   Nbr of phone lines
Nbr of pay phones
Fax   Nbr of fax machines
Is there internet access  
 
Feeding Capabilities
Kitchen   Food on Hand:   Days
Would your facility cook
for other locations		  
Vending Machines  
 
Number of Residents
Maximum Capacity
Number of Ambulatory  Non-Ambulatory 
Fire Safety System Automatic Fire Extinguisher  
Alarm System  
Approx. number of vehicles that can be accommodated in parking lot? Number 

Other
Does your facility have transportation vehicles  
If yes, please describe
if yes, what is the capacity of these vehicles?
Additional Comments:

Name of Person who completed survey:
Phone Number:   Ext: 

 

 

 


Contact Information

Office of Homeland Security / Emergency Management
200 Grand River, Suite 204
Port Huron, MI 48060

Phone: (810) 989-6965
Fax: (810) 989-6908
Email: emergencymanagement@stclaircounty.org
 
St. Clair County, Michigan

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