Host Quarterly Checklist

Community*
Community
Point of Contact*
Title*
Phone*
Email*
Enter Email Confirm Email
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.
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.*
Date Format: MM slash DD slash YYYY
REP Annual Update:
1. Any alterations, including relocation, of facilities reported to REP Planning.*
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.*
Date Format: MM slash DD slash YYYY
4. Any Local Letters of Agreement reviewed and updated.*
Date Format: MM slash DD slash YYYY
5. Plan and procedures reviewed and comments noted. Forwarded to REP Planning.*
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*
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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Host Quarterly Checklist

SIGNED COVER SHEET:

EOC

Equipment:

Training and Drills:

REP Annual Update:

Budgets:

RECEPTION CENTER

Equipment:

Training and Drills:

REP Annual Update:

VERIFICATION & CERTIFICATION:

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