Schuylkill County COAD Resource Survey Community Organizations Active in Disaster Organization Name:(Required) Agency Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Office Phone:(Required)Service Area:(Required) All of Schuylkill County Only specific municipalities Regional or Statewide Please specify service area:(Required) Organization ContactsThese are the staff that represent your organization on the COAD and/or would respond to a resource request during a disaster.Primary Contact:(Required) First Last Primary Contact Mobile Phone:(Required)Primary Contact Email:(Required) Secondary Contact:(Required) First Last Seondary Contact Mobile Phone:(Required)Secondary Contact Email:(Required) Services your Organization can provide during a DisasterFood & Water Coordination of Services Food Water Collection Distribution Storage Preparation Serve Infant Formula Provide Special Dietary Needs Other Please check all that applyOther/Additional Comments: Clothing Coordination of Services Collection Distribution Storage Cleaning Adult Child Infant Diapers Other Please check all that applyOther/Additional Comments: Shelter & HousingOur location can be utilized for Mass Care. Yes No Location: Capacity for # of PeopleNumber of Bathrooms:Number of Showers:Number of Cots:Number of Blankets/Bedding:Number of Cribs:Kitchen Available? Yes No Are Pets Accepted? Yes No Other/Additional Comments: Shelter Operations Shelter Management Set-up Intake Registration Shelter maintenance/cleaning Other Please check all that applyOther/Additional Comments: Short Term & Housing Items Shelter Hotel Voucher Bedding Furniture Appliances Kitchen items Damage Assessment Building Repair Building Materials Other Please check all that applyOther/Additional Comments: Transportation & WarehousingCoordination of Services: Yes No Available Vehicles Plane Truck Bus Van Car/SUV ATV/UTV Snowmobile Handicapped accessible vehicle Equipment Repair Fuel Other Please check all that applySupport Pilots Drivers Traffic Control Pick up/Delivery Staff Please check all that applyStorage Facility Refrigerated Freezer Dry Storage Please check all that applyOther/Additional Comments: MedicalCoordination of Services Yes No Medical Staffing Physicians Pharmacists Nurses EMT’s Med Techs Lab Techs Blood Collection Morgue Other Please check all that applyMedical Services Prescription Drugs Eyeglasses Hearing Aids Oxygen Medical Equipment First Aid Supplies Personal Hygiene Items Other Please check all that applyOther/Additional Comments: Social Services Coordination of Services Psychologists/Psychiatrists Social Workers Counselors Spiritual Services Referral Services Search and Rescue Trace Missing Persons Family Reunification Child Care Elder Care Foreign Language Interpreters Sign Language Visual Disabilities? Emotional/Physical Special Needs Other Please check all that applyOther/Additional Comments: Financial Assistance Rent Utility Bills Building Materials Prescription Drugs Emergency Travelers Aid Gasoline Home Heating Oil Other Please check all that applyOther/Additional Comments: Communications Coordination of Services Facility Phone Banks Phone Bank Staffing Cell Phones Radio Equipment HAM Radio Operators Computers Internet Services Data Entry Personnel Other Please check all that applyOther/Additional Comments: Coordination of Unaffiliated Volunteers Staff Management Registration Provide ID Badges Training Assignments Housing Transportation Meals Other Please check all that applyOther/Additional Comments: Pet & Animal Services Shelter and care Emergency Veterinary Services Other Please check all that applyOther/Additional Comments: Has your organization developed procedures to implement your disaster response services?(Required) Yes No Name of Staff Member completing this survey(Required) First Last Enter Email of Staff Member completing this survey(Required) Date Survey Completed(Required) MM slash DD slash YYYY Δ