EPZ Quarterly Checklist

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Point of Contact*
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Phone*
Email*
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Which quarter are you reporting?*
- 1 Qtr: July - Sept
- 2 Qtr: Oct - Dec
- 3 Qtr: Jan - March
- 4 Qtr: April - June
SIGNED COVER SHEET:
Please upload your SIGNED flat rate checklist cover sheet.*
Drop files here or

Accepted file types: pdf, jpg, gif, xslx, doc, docx, ppt, pptx, xsl, Max. file size: 1 GB.
A blank cover sheet can be found at this link. Flat Rate Checklist Cover Sheet.

Be sure to put this on community letterhead.
EQUIPMENT:
1. Communications tests completed.*
MM slash DD slash YYYY
2. Telephone numbers for personnel, facilities, and agencies verified.*
MM slash DD slash YYYY
3. Inventory checks completed.*
MM slash DD slash YYYY
4. Checks of EOC equipment (other than dosimetry and meters) completed.*
MM slash DD slash YYYY
5. Checks of dosimetry (Re-zeroing) and meters (checking background). Any equipment issues, report to RIMC.*
MM slash DD slash YYYY
Training and Drills:
1. All required training requested/needed completed.*
MM slash DD slash YYYY
2. Training plan for next year completed and approved by REP Planning (On Assessment Request).*
MM slash DD slash YYYY
3. Drills/Exercise Plan for next year completed and approved by REP Planning (On assessment request).*
MM slash DD slash YYYY
4. Participated in drills/exercises, workshops, TTXs as required.*
MM slash DD slash YYYY
REP Annual Update:
1. Any alterations, including relocation, of facilities reported to REP Planning.*
MM slash DD slash YYYY
2. Map accuracy checked for traffic/access control points.*
MM slash DD slash YYYY
3. Schools, day cares, and other special facilities identified and transportation needs updated. (In consult with Special Facilities Field Rep.)*
MM slash DD slash YYYY
4. Signatory page of the REP Plan signed by appropriate municipal official when elections held.*
MM slash DD slash YYYY
5. Any local letters of agreement reviewed and updated.*
MM slash DD slash YYYY
6. Plans and procedures reviewed and comments noted. Comments forwarded to REP Planning.*
MM slash DD slash YYYY
7. Any roadway changes due to maintenance, construction, or other projects reported to REP Planning.*
MM slash DD slash YYYY
PDAFN List:
1. Listing of citizens with disabilities and access/functional needs updated and verified.*
MM slash DD slash YYYY
Is your current PDAFN list revision number correct and up to date?*
To see your community's current Revision Number, please click here: PDAFN List Revision Numbers.
Please state what revision number you have that is current:*
Please upload your Persons with Disabilities and Access/Functional Needs (PDAFN) List*
Drop files here or

Accepted file types: pdf, jpg, gif, xslx, doc, docx, ppt, pptx, xsl, Max. file size: 1 GB.
Budgets:
1. Annual assessment request prepared and forwarded to HSEM by March 15th.*
MM slash DD slash YYYY
VERIFICATION & CERTIFICATION:
I certify that I am an authorized representative of the aforementioned community.*
- Yes
Statement of Acknowledgement*
By writing my full name below and clicking the submit button, I am attesting that the information I provided in this form is true and accurate to the best of my ability. I also acknowledge that failure to provide accurate and/or misleading information may be grounds for disqualification.

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EPZ Quarterly Checklist

SIGNED COVER SHEET:

EQUIPMENT:

Training and Drills:

REP Annual Update:

PDAFN List:

Budgets:

VERIFICATION & CERTIFICATION:

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