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Florida Division of Emergency Management

Facility Qualification Checklist

For determining whether to pursue healthy building upgrades

Please complete the following questionnaire to determine the feasibility of HVAC-related upgrades at your facility. Use only one form per property and provide additional comments as needed.

Fields marked with an * are required.

Site Information

*Site Owner/Operator

*Contact Name

*Email Address

*Phone Number

Property Information

*Property Name

*Property Location (City)

*Property Location (State)

*Building Size (in sq. ft.)

*Building Age (in years)

*Facility Type

*Number of Residents

Typical Resident Room Size (in sq. ft.)

Common Area Sizes (in sq. ft.), please list

Basic HVAC Systems Used

Note vintage, condition, how well it is performing, any planned upgrades.

*Resident Rooms

*Dining Areas

*Common Spaces

*Staff Areas

*Additional System(s)

*Ability to handle additional heating/cooling loads

*Is the equipment, including controls, maintained by your staff or hired out?

Other HVAC comments

Mechanical Ventilation

How are the various care areas within the facility provided with outdoor air, including its control (i.e., central control vs. individual control by the resident)?

*Resident Rooms

*Dining Areas

*Common Spaces

*Staff Areas

*Additional System(s)

*How are the resident rooms exhausted?

*How is the exhausted air made up?

Other ventilation comments

Filtration

*What is the general filtration level for each area? Are there any additional filters that are used in the central equipment?

*Are there ultraviolet lights installed in the HVAC equipment?

General Comments

*Are there any “hot spots” where acquired infections may occur/concentrate that need to be focused on first? If so, please explain.

Please provide any additional information about your facility that you think may be helpful.

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