emerg prep survey
TRANSCRIPT
8/8/2019 Emerg Prep Survey
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MERGENCY PREPAREDNESS SURVEY
rivacy Notice: This survey is voluntary, however the more we know about you, your state of preparedness, and potential needs, the mo
we can all be prepared to help each other in case of an emergency. Your privacy is important and the information given below will only b
iewed by the Emergency Preparedness Coordinator and the Bishopric and will not be shared with anyone else.
amily
ensus
merg.
ontacts
torage
its
upplies
& Gear
kills &
raining
We can
amily
Members
Last Name: _________________________ Phone: ___________________________ Email: _________________________
Address: ___________________________________________________________________
Years _______ Months _________ at current address. We plan to be here: short term, long term, don’t know
Total # in Household: _______, Adults _______, Teen Boys: _______, Teen Girls: _______, Kids 12 and under:_______.
Local: ___________________________________ Location: _______________________ Phone: _____________________
Away: ___________________________________ Location: _______________________ Phone: _____________________
Food Storage: ________ months. Water: ________ weeks. Fuel ________ weeks.
1st
Aid 72 -hr Tool Pet Hygiene Shelter in Place Fun (kids) Hunting Water Purific
Tent AM/FM Radio Extra Blankets Pry Bar Generator
Batteries Walkie Talkies Solar Oven Heat Packs Rope/TarpsCoats/ Poncho Ham Radio Small Propane Fire Extinguisher Hydraulic Jack
Pick-up Truck Large Propane Torch Welder Backpacks Matches
Ax/Hatchet Chainsaw Camp Stove Flashlights Seeds/Veg.
Cot Sleeping Bag Water Purifier Candles Dutch Oven
Other: ___________________________________________________________________________________________
1st
Aid/CPR CERT Shelter Mgmt. Nurse Gardening/Farming
Counseling EMT/Medic Plumbing Electrical Emerg. Mgmt.
Ham Radio Carpentry Heavy Equip Welding Livestock/Poultry
Callsign: _________ Bldg. Inspector Fire Fighting Security Language(s):
Doctor Mechanic Military Dentist _____________________
Solar Power Morse Code Engineering Midwife Candle/Soap MakingOther: ___________________________________________________________________________________________
Assist Block Captain Render Aid Use Skills Share what we have (after personal needs are met)
Offer extra room(s) for _________ people in case of emergency.
How/where to reach Special Needs: meds diabetic, disabilities, car,
First Name Ages Work/School/Phones/Email asthma,/allergies, O2, dietary, mobility, pets, langu
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Put additional names and needs on back