Disaster Preparedness Award

SECTION 1
Nominator Information Please complete the following information for the person completing this nomination.
Nominator Full Name *
Nominator Organization *
Nominator Professional Title
Nominator Address (Include City, State, and Zip) *
Nominator Phone *
Nominator Email Address *
SECTION 2
Organization General Information Complete the following fields related to the organization being nominated for the award.
Facility Name
Utility Name
Facility Type	Water Treatment Water Distribution Wastewater Collection Wastewater Treatment
Facility Address (Include City, State, and Zip)
Facility Contact Person and Professional Title
Contact Person Phone Number
Contact Person Email
SECTION 3
Utility Memberships Please indicate which (if any) the organization has a membership with.
Memberships (select all that apply)	AWWA WEF
SECTION 4
Organization Preparedness Programs For the checklist below, only check the programs which are currently in place at the utility, or that the utility has preformed. Provide additional information when asked to do so. Any additional information may be attached in a separate document and uploaded at the end of the form.
Service Population (Based on USEPA Vulnerability Assessment Criteria)
Indicate which of the following the nominated utility has in place or has performed	Water Vulnerability Assessment completed. Water Emergency Operations Plan (EOP) completed. Wastewater Vulnerability Assessment completed. Wastewater Emergency Operations Plan completed All staff trained in EOP. Drought management plan and/or water conservation plan developed. Written disaster response manual in the hands of all supervisors. Departmental emergency call list maintained. Parent agency (municipality or county) has executed the NC Local Government Mutual Aid Agreement Internal water incident tabletop exercise(s) conducted. Emergency water interconnections with other systems in place At least one person in the utility has studied the EPA Response Protocol Toolbox. Drafts of key possible notices to customers have been prepared and are available. Key facilities have been surveyed by one or more law enforcement agencies. Disaster planning has been done with local police agency. Disaster planning has been done with local fire department Communication is maintained with county health department. Utility has capability of modeling water distribution system Major facilities have provisions to sustain staff in the event of “lock-down”
Designated disaster preparedness person on staff?
If you answered 'Yes' to previous question, please provide their name here:
One or more staff is certified in the Incident Command System or National Incident Command System?
If you answered 'Yes' to previous question, provide their name here:
Emergency electrical generators at facilities
Has provided disaster intrastate mutual aid
Specify event(s) and aid recipient(s):
Has provided disaster interstate mutual aid
Specify event(s) and aid recipient(s
Other disaster preparedness/security initiatives:
SECTION 5
Uploading Supporting Documents If you would like to upload responses to open-ended questions, or additional materials, please convert them to PDF format and merge all documents into a clearly labeled file.
Upload any supporting documents here