Small / Medium Organization Single Site Questionnaire

Name of Organization:
Address:
Authorized Representative of Organization:
Phone:
Fax:
E-Mail:
Are you a service or product based organization?	Please Select One Service Product Both
Please indicate what best describes your organization	Please Select One Insurance Company, Bank or Credit Union School, College, University or Technical Institution Airline, Bus Company or Mass Transportation System Maritime Port or Cruise Line Hotel, Casino, Resort or Resort Community Privately Owned / Public Venues (Stadium, Arena, Zoo, Museum, etc.) Multi Site Manufacturing / Distribution Organization Hospital, Residential Short and/or Long Term Health Care Facility Commercial Real Estate Owner Facility/Property Management School, College, University and/or Technical Institution First Response Entity Disaster/Emergency Relief Aid Organization (NGO's) Post Disaster/Emergency Recovery Entity Corporation Small to Medium Business Enterprise Manufacturing and/or Industrial Entity Manufactured Home Community Managed Senior Home Community and/or Apartment Complex Nursing Home, Assisted Living and/or Day Care Facility Other
Other business description:
Describe the product(s) and/or services(s) that you provide; including any maintenance activities associated with the product(s) or service(s).
Number of individuals on the immediate site affected by your operations (i.e. number of employees, residents, guests, etc.):
Number of units affected by your operations (i.e. plants, out buildings, homes, individual apartments, etc.):
Please provide a brief physical description of the units above i.e. square footage, number of rooms, hazardous materials stored in unit, etc.
Is the facility in a natural disaster prone area i.e. hurricane, tornado, earthquake, landslide, floodplain, etc. (Please explain)
Please indicate the most common potential hazards that could affect your Organization or community:	Geological Earthquake Tsunami Land/Mudslide Meteorological Flood/Tidal Surge Drought Fire Snow Tornado/Hurricane Extreme Temperature Biological Disease Infestation Accidental Hazardous Material Explosion Transport Related Facility Issues Gas/Power Interruption Air/Water Pollution Intentional Terrorism Civil Disturbance Crime/Arson
Have you had any significant emergency events in the past 3 years that required outside intervention (fire department, HazMat, police, etc.); include a brief description (i.e. 2005 warehouse fire)?	Please Select One Yes No
Significant Emergency Details
Have you been impacted by a natural or technological event in the past 3 years that was outside of your property/control and disrupted your normal operations; include a brief description (i.e. 2002 lightning strike on power substation, no power for 16 hours)?	Please Select One Yes No
Significant Natural Event Details
List any facilities or operations in the nearby area that could affect your operations in the event of a disaster i.e. chemical processing facility, petrochemical storage facility, manufacturing operations, rail yards, airports, etc.
Please define the area covered by your organizational plan or certification i.e. square footage of facility, acreage of property, number of stories in building, etc.
Does your Organization operate with an existing Disaster Recovery Plan (IT/Data centric, vital records, off-site storage etc.)?	Please Select One Yes No
Is your Organization currently prepared by having and maintaining a fully comprehensive “All Hazards” Disaster/Emergency and Business Continuity Plan and/or Program?	Please Select One Yes No
Do you feel this plan and/or program meets the requirements of NFPA 1600?	Please Select One N/A Yes No
Does your Organization maintain a budget dedicated to emergency preparedness, response, recovery and resumption?	Please Select One Yes No
Does your Organization have a supply chain (i.e. parts, distributors and/or other service providers) that affect your ability to operate?	Please Select One Yes No
Do your suppliers have and maintain a Disaster/Emergency and Business Continuity Plan and/or Program?	Please Select One Yes No
Do your suppliers operate in a natural disaster prone area i.e. hurricane, tornado, earthquake, landslide, floodplain, etc?	Please Select One Yes No
Do your suppliers operate in a pandemic or terrorist prone area?	Please Select One Yes No
Have your suppliers established Contingency/Aid agreements to continue uninterrupted in supplying your Organization with product and/or services?	Please Select One Yes No
Does your Organization operate with an existing Quality or Environmental Management System (i.e. ISO 9001:2000, ISO 14001 etc)?	Please Select One Yes No
Does your Organization currently undergo other compliance auditing (i.e. Sarbanes-Oxley, regulatory or other)?	Please Select One Yes No
Have you had an on-site visit by any oversight/regulatory authority (OSHA, EPA, DEQ, etc.) in the past 3 years; include a brief description (i.e. 2004 OSHA accident investigation)?	Please Select One Yes No
Visit Details
Is your Organization willing to commit to a Stage 1 on site readiness review conducted by NEMR. This is considered a contractual agreement to allow NEMR to conduct an on site visit and assess your organizations level of readiness for a complete audit to the requirements of NFPA 1600.	Please Select One Yes No
Is your Organization willing to commit to a desktop assessment (review) of your emergency preparedness and business continuity program documentation i.e. manuals, procedures, instructions, etc.	Please Select One Yes No