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

  ___________________ ____ __________________________ _______________________________________

  ___________________ ____ __________________________ _______________________________________

  ___________________ ____ __________________________ _______________________________________

  ___________________ ____ __________________________ _______________________________________

  ___________________ ____ __________________________ _______________________________________

  ___________________ ____ __________________________ _______________________________________

  ___________________ ____ __________________________ _______________________________________

  ___________________ ____ __________________________ _______________________________________

Put additional names and needs on back