Shelter Questionnaire |

Shelter Activation Form / Questionnaire

The shelter activation form/questionnaire below shall be completed with as much information as possible.

Before submission please verify that all information is correct.

* If needed, someone from our agency will follow-up with the contact person to obtain additional information and/or discuss items completed within the questionnaire submission.

1. Person Reporting Shelter *

Name of person completing this document

2. Person Reporting Phone # *

3. Person Reporting Email *

4. Indicate your affiliation with the Shelter

Affiliate of shelter site - Representative or Staff member
Municipal / Local Emergency Management Coordinator
Other Municipal Official
Other / Not Listed - *Please provide affiliation/title below in Question #20

5. Are you (the Person Reporting) also the Shelter Point-of-Contact Person? *

YES - Skip to Question #10
NO - Answer Questions #6 through #9 below

6. Shelter Point-of-Contact Person

7. Shelter Point-of-Contact Phone #

8. Shelter Point-of-Contact Email

9. Indicate the Point-of-Contact persons affiliation with the Shelter

Affiliate of shelter site - Representative or Staff member
Municipal / Local Emergency Management Coordinator
Other Municipal Official
Other / Not Listed - *Please provide affiliation/title below in Question #20

10. Shelter Location Name / Site

Name of facility, school, government facility hosting shelter

11. Shelter Location Street Address *

Example: 123 Main Street

12. Municipality *

Please choose the correct municipality from the drop down list

13. Services Type *

Warming
Cooling
Charging
Other - *Please provide services not listed in Question #20

Select all that apply

14. Additional Shelter Accommodations

Showering facilities
Overnight sheltering
Refreshments
Other - *Please provide accommodations not listed in Question #20

Select all that apply

15. Pet Friendly *

16. Shelter Availability *

Shelter available to everyone (includes non-municipal residents)
Shelter available to ONLY municipal residents

17. Maximum Occupancy - (daytime)

If known - provide max occupancy for daytime sheltering

18. Maximum Occupancy - (overnight)

If known - provide max occupancy for overnight sheltering

19. Any unmet needs or additional assistance requested?

Assistance for special needs residents, additional equipment, etc. Write in your agency/departments needs.

20. Additional Information (include days/dates & hours of operation) *

Utilize this box to provide the shelters days/hours of operation as well as any other information you would like shared.