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REP
Host Quarterly Checklist
Community
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Point of Contact
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Title
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Phone
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Email
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Which quarter are you reporting?
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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.
A blank cover sheet can be found at this link.
Flat Rate Checklist Cover Sheet
.
Be sure to put this on community letterhead.
EOC
Equipment:
1. Communications tests completed.
*
Date Format: MM slash DD slash YYYY
2. Telephone numbers for personnel, facilities, and agencies verified.
*
Date Format: MM slash DD slash YYYY
3. Inventory checks completed.
*
Date Format: MM slash DD slash YYYY
4. Checks of Equipment (other than dosimetry and meters) completed.
*
Date Format: MM slash DD slash YYYY
5. Checks of dosimetry (Re-zeroing) and meters (checking background). Any equipment issues, report to RIMC.
*
Date Format: MM slash DD slash YYYY
Training and Drills:
1. All required training requested/needed completed.
*
Date Format: MM slash DD slash YYYY
2. Training plan for next year completed and approved by REP Planning (On Assessment Request).
*
Date Format: MM slash DD slash YYYY
3. Drills/Exercise Plan for next year completed and approved by REP Planning (On assessment request).
*
Date Format: MM slash DD slash YYYY
4. Participated in drills/exercises, workshops, TTXs as required.
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Date Format: MM slash DD slash YYYY
REP Annual Update:
1. Any alterations, including relocation, of facilities reported to REP Planning.
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Date Format: MM slash DD slash YYYY
2. Map accuracy checked.
*
Date Format: MM slash DD slash YYYY
3. Signatory page of REP plan signed by appropriate municipal official when elections held.
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Date Format: MM slash DD slash YYYY
4. Any Local Letters of Agreement reviewed and updated.
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Date Format: MM slash DD slash YYYY
5. Plan and procedures reviewed and comments noted. Forwarded to REP Planning.
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Date Format: MM slash DD slash YYYY
6. Any roadway changes due to maintenance, construction, or other projects reported to REP Planning.
*
Date Format: MM slash DD slash YYYY
Budgets:
1. Annual assessment request prepared and forwarded to HSEM by March 15th.
*
Date Format: MM slash DD slash YYYY
RECEPTION CENTER
Equipment:
1. Communications tests completed.
*
Date Format: MM slash DD slash YYYY
2. Telephone numbers for personnel, facilities, and agencies verified.
*
Date Format: MM slash DD slash YYYY
3. Inventory checks completed.
*
Date Format: MM slash DD slash YYYY
4. Checks of Reception Center Equipment (other than dosimetry and meters).
*
Date Format: MM slash DD slash YYYY
5. Checks of dosimetry (re-zeroing) and meters (checking background). Any equipment issues reported to RIMC.
*
Date Format: MM slash DD slash YYYY
6. Assembly and functional check of Portal monitor completed.
*
Date Format: MM slash DD slash YYYY
Training and Drills:
1. All required training requested/needed completed.
*
Date Format: MM slash DD slash YYYY
2. Participated in Drills/exercises, Workshops, TTXs as required.
*
Date Format: MM slash DD slash YYYY
REP Annual Update:
1. Facilities inspected for any alterations, including relocation. Report to REP Planning.
*
Date Format: MM slash DD slash YYYY
2. Any Local Letters of Agreement reviewed and updated.
*
Date Format: MM slash DD slash YYYY
VERIFICATION & CERTIFICATION:
I certify that I am an authorized representative of the aforementioned community.
*
Yes
Statement of Acknowledgement
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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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REP
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