Reach Out America – Organizational Capabilities Assessment
Name of Church/Pastor:
*
Date:
Position in Organization:
Phone:
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Email:
Organization Address:
Organization Email
Web URL:
Organization Type:
Faith-Based Organization
UPCI
Community Based Organization
Number of Members Total:
Does your organization have a Disaster or Emergency Plan in place?
Yes
No
What services/resources do you provide on a daily basis to your members or community?
Child Care
Clothes Distribution
Commercial Kitchen
Community Center
Counseling
Food/Commodities Pantry
Medical Services
Security
Shelter
Transportation
Disability Access
Other
Would your organization be willing to provide any of these services in an emergency?
Yes
No
How is your facility/organization equipped to fulfill the services that you provide? (e.g., space, kitchen, equipment)
Do you have space to temporarily store product in preparation for distribution? (church hallways, gymnasiums, fellowship halls, or other buildings/space)
Yes
No
Any chance you have access to a borrowed/owned warehouse space of 5,000 to 10,000 square feet? (if not, that's okay)
Yes
No
Do you have a space with a dock for the unloading of a semi-truck? (if not, that's okay)
Yes
No
Is your facility equipped with a generator?
Yes
No
Please provide information regarding the occupations and skills of members of your organization who may be able to serve the community in a crisis (please note any training or certifications obtained, as applicable/available):
Chaplain / Spiritual Care Providers
Crisis Counselors
Individuals Trained in Cardiopulmonary Resuscitation (CPR)/First Aid
Interpreters (please include languages, to include American Sign Language)
Medical Doctors
Nurses / Licensed Vocational Nurses
Paramedics/ Emergency Medical Technicians
Retired Public Safety Personnel
Teachers/Child Care
Veterinarian or Animal Care Services
Other (e.g., amateur radio operators)
Does your organization have the ability to distribute food or other commodities to the community during a small or large-scale incident?
1- Small Scale Incident
2
3
4
5- Large Scale Incident
If yes, how many meals can your organization prepare and serve each day?
Does your organization have the ability to deliver food?
Yes
No
Option
Does your organization have a shelter space available for use during a small or large-scale incident?
Yes
No
If yes, what is the size (including square footage) and type of space that is available for sheltering?
How many people can be sheltered?
Can people with disabilities and others with access and functional needs use this facility?
Yes
No
Are non-service animals permitted in or around the shelter space?
Yes
No
Does your organization have a licensed or certified childcare facility?
Yes
No
If yes, is your organization willing to serve community members and children who need assistance following an incident?
Yes
No
What is your maximum childcare capacity?
Can your organization provide mental, emotional counseling during a small or large-scale incident?
Yes
No
If yes, how many licensed/certified/trained counselors will your organization be able to provide?
Does your organization have a communication system to activate in response to a small or largescale incident?
Yes
No
If yes, what type of system do you have (e.g., amateur radio, phone tree)?
Who does the system reach (e.g., community members, employees)?
Does your organization accept donations?
Yes
No
If yes, what type (e.g., food, clothing, money)?
Does your organization distribute donations through case management?
Yes
No
Does your organization have the ability to mobilize volunteers to assist the community during a small or large-scale incident?
Yes
No
If yes, how many volunteers could your organization provide at one time?
Are there additional services that your organization would be able to provide during a small or large-scale incident?
What type of assistance do you believe your organization will need to prepare in advance for organizational preparedness/continuity?
Communications
Developing Partnerships
Donations Management
Mass Care Feeding
Organizational Preparedness/Continutity
Service Coordination
Sheltering
Spiritual and Emotional Care/Counseling
What type of assistance do you believe your organization will need to respond to or recover from a small or large-scale incident (e.g., debris removal, interpreters)?
Are you a part of, or aware of, other organizations/networks that provide similar community services?
Yes
No
How can we best partner with you?
Email updates (optional)
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