EMERGENCY PREPAREDNESS SURVEY

Privacy Notice: This survey is voluntary, however the more we know about you, your state of preparedness, and potential needs, the more
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 be
viewed by the Emergency Preparedness Coordinator and the Bishopric and will not be shared with anyone else.

Family Last Name: _________________________ Phone: ___________________________ Email: ____________________________

Address: ___________________________________________________________________

Years _______ Months _________ at current address. We plan to be here: short term, long term, don’t know

Census Total # in Household: _______, Adults _______, Teen Boys: _______, Teen Girls: _______, Kids 12 and under:_______.

Emerg. Local: ___________________________________ Location: _______________________ Phone: _______________________

Contacts
Away: ___________________________________ Location: _______________________ Phone: _______________________

Storage Food Storage: ________ months. Water: ________ weeks. Fuel ________ weeks.

Kits st
1 Aid 72 -hr Tool Pet Hygiene Shelter in Place Fun (kids) Hunting Water Purification

Supplies Tent AM/FM Radio Extra Blankets Pry Bar Generator

& Gear Batteries Walkie Talkies Solar Oven Heat Packs Rope/Tarps
Coats/ 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: ___________________________________________________________________________________________

st
Skills & 1 Aid/CPR CERT Shelter Mgmt. Nurse Gardening/Farming
Training 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 Making
Other: ___________________________________________________________________________________________

Assist Block Captain Render Aid Use Skills Share what we have (after personal needs are met)
We can 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, language
Family ___________________ ____ __________________________ ___________________________________________
Members
___________________ ____ __________________________ ___________________________________________

___________________ ____ __________________________ ___________________________________________

___________________ ____ __________________________ ___________________________________________

___________________ ____ __________________________ ___________________________________________

___________________ ____ __________________________ ___________________________________________

___________________ ____ __________________________ ___________________________________________

___________________ ____ __________________________ ___________________________________________

Put additional names and needs on back