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Lemhinhn PREPAREDNESS HOUSEHOLD SURVEY
Date: __________________________
In the event of a disaster, neighbors need to know the following information to aid in potential disaster relief efforts:
Head of Household: _______________________________
Special Needs: _________________________________
__ Illness __ Disabled __ Wheelchair Bound __ Bedridden __ Oxygen
__ Sight Impaired __ Hearing Imp __CPAP/BIPAP, Other:
Home Address: ____________________________________
Home Phone: _________________________________
E-Mail: _____________________________________
Cell Phone: ___________________________________
Employer: ________________________________________
Work Phone: _________________________________
E-Mail: _____________________________________
Pager: _______________________________________
Special Skills (medical, communication, security, construction, social/counseling, dietary/food, other):
___________________________________________________________________________
___________________________________________________________________________
Spouse: __________________________________________
Special Needs: ________________________________
__ Illness __ Disabled __ Wheelchair Bound __ Bedridden __ Oxygen
__ Sight Impaired __ Hearing Imp __CPAP/BIPAP, Other:
Employer: ________________________________________
Work Phone: _________________________________
E-Mail: _____________________________________
Cell Phone: ___________________________________
Special Skills (medical, communication, security, construction, social/counseling, dietary/food, other):
___________________________________________________________________________
___________________________________________________________________________
Children or Others (living in home):
Full Name, School/Other, Temporary Care Giver, Special Needs
___________________________ ____________________ ____________________
___________________________ ____________________ ____________________
___________________________ ____________________ ____________________
___________________________ ____________________ ____________________
___________________________ ____________________ ____________________
___________________________ ____________________ ____________________
Special Tools/Equipment (that could aid in disaster relief):
Available Household Emergency Resources (Please check all that you could make available in an emergency)
__ First Aid Supplies __ Amateur Radio __ Walkie Talkies __ Gas or Briquette Grill __ Gasoline in Containers
__ Lantern/Portable Lights __ Portable Generator __ Portable Pump __ Over 10’ Ladder __ Chain Saw __ Ax
__ Bolt Cutters __ Heavy Duty Jack __ Winch __ Rope/Cables
__ Crowbar/Pry Tools __ All Terrain Vehicle
__ 4-Wheel Drive Vehicle __ Construction Equip __ Earthmoving Equip (tractor, wheelbarrow, etc.) __ Hand Tools
__ Other Maintenance or Repair Tools __ Snow Plow __ Shelter (tent, camp trailer, RV near home) __ Bedding (cots, Blankets, etc.) __ Other Useful Equip ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Other Person(s) in Your Neighborhood with Special Skills/Equipment (name, address, phone, skills/equipment):
Householder Skills (Please check appropriate skills of any household member able to assist in an emergency)
__ Administration __ Amateur Radio Operator __Carpentry/Construction __ Computer __ Childcare __Crisis/Psych __Counseling __ Damage Assessment __ Electrical __ Engineering
__ Fire Fighting __ First Aid/CPR __ Heavy Equip Operator
__ Language Translation: _______ __ Law Enforcement/Security
__ Medical (Dr., Nurse, EMT, Paramedic) __ Plumbing __ Search & Rescue __ Shelter Operator __Utilities: __ Other: ______________________________________________________________________________________________________________________________________________________
Specialized Training (Please list education, training, experience you/household members have for items checked): __________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Local Relative/Emergency Contact (include name, relationship, address, phone number/s):
___________________________________________________________________________
___________________________________________________________________________
Out-of-State Emergency Contact (include name, relationship, address, phone number/s):
___________________________________________________________________________
___________________________________________________________________________
Describe Special Neighborhood Concerns (power outage, flooding, special medical needs): __________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Are you able to offer a place for others to stay (available housing, yard space, etc.)?: _____ Yes _____ No
Description: ___________________________________________________________________________
___________________________________________________________________________