Site Assessment Form - Homeless Service Sites

Version 2.0 Form Approved

Last Updated 09.07.2022 OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

Site Assessment Form for Homeless Service Sites Date of Assessment:
Name of facility:					Name of Observer:
Address:					N° people served per day:		Sq ft:
Type of facility: ☐ Day center ☐ 24/7 shelter ☐ Supportive/Transitional housing ☐ Other:_________________					Hours of operation:
					Ownership: ☐ Public ☐ Private ☐ Non profit ☐ Other:_______________
Site POC: ______________ ___________________ _____________________ Name Position Phone #
Staff
# Permanent Staff on Site: # Volunteer/Temp Staff on Site:					Medical services available on site: ☐ Y ☐ N If yes, clinician type:
					Veterinary services available on site: ☐ Y ☐ N If yes, type:
Facilities
Laundry facilities? ☐ Y ☐ N If yes: Laundry on site?: ☐ Y ☐ N Clothing laundered by the facility?: ☐ Y ☐ N Bedding/linens laundered by the facility? ☐ Y ☐ N Are bath towels laundered separately from clothing? ☐ Y ☐ N ☐ Not monitored
Are laundry baskets/bags provided? ☐ Y ☐ N If yes: Does each client have their own or are they shared? ☐ Baskets are not provided ☐ Individual ☐ Shared ☐ Unknown
Are clients able to launder items themselves? ☐ Y ☐ N					Are clients able to bring in items for laundry? ☐ Y ☐ N
# Showers:					Do showers always have available hot water? ☐ Y ☐ N
# Total Beds:					# Beds Filled Per Night (on average):
# Beds filled night prior to assessment: _________
# Female Beds:			# Male Beds:			# Non-assigned Beds:
# Individual Rooms:	# Twin Rooms:	# Family rooms:		# Congregate Sleeping Areas & Capacity:		# Dorm style rooms & capacity: 3-4 ppl________ 8-20 ppl__________ 4-8 ppl________ > 20 ppl __________
Are isolation areas available for people with infectious diseases or infestations? ☐ Y ☐ N If yes, how many: ______________
Are bed/mats assigned to one person? ☐ Y ☐ N					Are beds/mats stacked nightly? ☐ Y ☐ N
Distance between beds in sleeping area: At least 3 Feet: ☐ Y ☐ N If no, distance between beds:					Bed linens provided? ☐ Y ☐ N Blanket only
					Are linens always washed in hot water? ☐ Y ☐ N
Is bedding laundered between each client? ☐ Y ☐ N					How often linens changed/washed? __________________
Is a “hot box” used to treat personal belongings? ☐ Y ☐ N					Is upholstered furniture present? ☐ Y ☐ N
Is carpet present? ☐ Y ☐ N					If upholstered furniture is present, is it steam-cleaned? ☐ Y ☐ N
If carpets are present, are they steam-cleaned? ☐ Y ☐ N					Are bedbug-resistant mattresses provided? ☐ Y ☐ N
Are mattress covers changed or sanitized between clients? ☐ Y ☐ N					Are spaces inspected for bedbugs and/or lice? ☐ Y ☐ N
Is there a current rodent infestation? ☐ Y ☐ N					Has there been a rodent infestation in the past 3 months? ☐ Y ☐ N
Is clothing donated to clients ☐ Y ☐ N					Is sharing of bedding or sleeping bags allowed? ☐ Y ☐ N ☐ Not monitored
Is clothing laundered before donating to clients? ☐ Y ☐ N ☐ Not monitored
Is sharing of coats allowed? ☐ Y ☐ N ☐ Not monitored					Is sharing of other clothing allowed? ☐ Y ☐ N ☐ Not monitored
Are pets or service/companion animals allowed? ☐ Y ☐ N					If yes, are flea control services/medications provided? ☐ Y ☐ N
If yes, where do the animals sleep? __________					If yes, what kind of animals are allowed? ☐ Dogs ☐ Cats Other: _____

Name of Facility:

Additional Comments: please note contextual information that may be important to document related to preventative measures, practices taken regarding vectorborne diseases (e.g., how are educational trainings for staff or clients/guests typically done at this site), etc.

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX