Home > Teen Challenge > Teen Challenge Survey Teen Challenge Survey Step 1 of 6 - Contact 16% Contact InformationName of Teen Challenge Center*Address of Teen Challenge Center* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Contact Phone Number*Contact Email* InsuranceApproximately how many times a year do you interact with your insurance agent or risk manager?012345+Please rate your satisfactions with your current insurance program in regards to Annual Pricing Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied Please rate your satisfaction with your current insurance program in regards to answering your questions Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied Please rate your satisfaction with your current insurance program in regards to quickness of response Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied Would you be interested in switching insurance companies if it reduced costs and improved your understanding of safety and protection of the ministry?YesNo, I am satisfied with my current programWould you be willing to switch insurance agents to obtain a program that reduced costs and improved your understanding of safety and protection of the ministry?YesNoI would prefer to keep my agent because they are involved in the ministryWhat are the insurance companies used and the approximate annual costs for your following policies?Worker's CompensationCompanyAnnual Cost AutomobileCompanyAnnual Cost Package (General Liability, Property, Professional, Crime)CompanyAnnual Cost Directors & OfficersCompanyAnnual Cost UmbrellaCompanyAnnual CostApproximate Annual Operating Budget Board of Directors / LeadershipHow many people serve on your Board of Directors?# Female# Male Do you currently have the appropriate number of trustees so that you are in compliance with your Constitution and Bylaws?YesNoDoes the board of directors commission a committee that has risk management as its purpose?YesNoAre both federal and state criminal background checks conducted on all staff and students?YesNoHave all staff been given written job descriptions or job portfolios?YesNoAre the formal complaint procedures supplied and explained to all students and staff?YesNoIs there a formal response plan communicated to all staff and students for the following:FireYesNoExtreme WeatherYesNoActive ShooterYesNoPhysical AltercationsYesNoMedical EmergenciesYesNoAre students involved in any of the following work for the center or as work teams on behalf of the center:Kitchen/ Food PreparationYesNoLandscapingYesNoRoofingYesNoJanitorialYesNoSnow RemovalYesNoCarpentryYesNoOtherDo you have any of the following professionals on staff or contracted? If yes, please provide the approximate number. If no, please leave blank.Pastoral counselors - licensed# Employees# Contracted Pastoral counselors - un-licensed# Employees# Contracted Educationally qualified counselors (M.A., MSW, Etc.) - licensed# Employees# Contracted Un-licensed counselors# Employees# Contracted Un-licensed counselors# Employees# Contracted LPN's# Employee# ContractedRN's# Employee# ContractedPsychiatrists# Employee# ContractedPsychologists# Employee# ContractedSocial Workers# Employee# ContractedPhysicians# Employee# ContractedNurse Practitioner# Employee# Contracted CampusIs there a designated part of the operating budget allocated to improving the physical campuses?YesNoIs there at least one staff member who has the responsibility of maintenance and improvement of the campus as part of their written job description?YesNoPlease provide the number of locations and information about eachName or Description of locationStreet AddressCity, State, Zip# of Students# of Staff Please provide information regarding each of your locations including a brief description, i.e. soup kitchen, residential center, thrift store, etc.Do all dormitories have the following:SprinklersYesNoFire ExtinguishersYesNoCentral Station Fire AlarmYesNoCentral Station Burglar AlarmYesNoIlluminated Exit SignsYesNoWhat part of the campus needs the most attention in regards to maintenance? Auto:Approximate # of vehicles owned by the centerAre Motor Vehicle Reports obtained for all staff prior to allowing them to drive vehicles?YesNoIs formal driving training supplied to all staff before they are allowed to drive vehicles on the organization’s behalf?YesNoDo you have a formal re-training policy for staff after they have had an accident?YesNoDo you have a formal maintenance schedule for the organization’s vehicles?YesNoIs the maintenance of the vehicles a written responsibility within a certain staff member’s job description?YesNo Comments & FeedbackWhat insurance or risk management issue is the most frustrating to you?What insurance or risk management issue do you wish you had more guidance or help with?List This iframe contains the logic required to handle Ajax powered Gravity Forms.