Site Assessment Form - Street/Outreach Workers

Version 2.0 Form Approved

Last Updated 09.07.2022 OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

Site Assessment Form for Street/Outreach Workers Date of Assessment:
Location of Outreach Team (City, State):	Name of Observer:
Number of Encampments Served by Team:	Average Number of Clients Served per Day: ____ Per week: _____
Days Each Week Outreach Team in Field:	Hours of Operation:
How many encampments are visited on a weekly basis?:___________	Funding Source: ☐ Public ☐ Private ☐ Non profit ☐ Other:_________
Site POC: ______________ ___________________ _____________________ Name Position Phone #
Staff
# Permanent Staff on Outreach Team: # Volunteer/Temp Staff on Outreach Team:	Medical services provided during outreach visits: ☐ Y ☐ N If yes, clinician type:
Clothing or bedding donated during outreach visits: ☐ Y ☐ N If yes, type:	Veterinary services provided during outreach visits: ☐ Y ☐ N If yes, type:
Facilities
Do clients have regular access to laundry services? ☐ Y ☐ N If yes: Clothing laundered?: ☐ Y ☐ N Bedding/linens laundered? ☐ Y ☐ N
Where do they clients access laundry services? _________________________
Are clients able to launder items themselves? ☐ Y ☐ N	Are clients able to bring in items for laundry? ☐ Y ☐ N
Is hot water always available for laundry? ☐ Y ☐ N	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
Do clients have regular access to showers? ☐ Y ☐ N	If yes: Do showers have available hot water? ☐ Y ☐ N
About what percentage of clients have pets or companion/service animals? _____%	Are flea control services/medications provided by the outreach team? ☐ Y ☐ N
What type of pets or companion/service animals are in the encampments? ☐ 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 / clients 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