Emergency Preparedness

Neighborhood Resource Survey

(Pre-Disaster Assessment of Family Skills and Resources)

Last Name:___________________________________________________ Date Surveyed:______________________________

Address:________________________________________________________________________________________________

Home Phone:________________________ Work Phone:________________________ Cell Phone:_______________________

Email Address:___________________________________________________________________________________________

Nearest Relative:__________________________________ Relation:______________________ Phone:___________________

Out of State Contact:____________________________________________________________  Phone:___________________

Family Members/People Living at Home                                                               Special Needs and Health Considerations

1.____________________________________________                       __________________________________________________

2.____________________________________________                       __________________________________________________

3.____________________________________________                       __________________________________________________

4.____________________________________________                       __________________________________________________

5.____________________________________________                       __________________________________________________

6.____________________________________________                       __________________________________________________

7.____________________________________________                       __________________________________________________

8.____________________________________________                       __________________________________________________

9.____________________________________________                       __________________________________________________

10.___________________________________________                       __________________________________________________

(Use the back side to list additional people or family members and special needs.)

In the event of a disaster, what skills do members of your household have?  What resources do you have?

General Skills                                        Name of Family Member(s)             Medical Skills                                          Name of Family Member(s)

Appliance Repair                                                                                                 Professional (type)

Automotive Repair                                                                                               CERT/NEST

Bus Driver                                                                                                               Other

Computer Skills

Day Care Training                                                                                                 Government/Utilities

Dietitian                                                                                                                   Police

Foreign Language                                                                                                 Firefighter

                ________________________                                                            Military

                ________________________                                                            Utilities (type)

Sign Language

Ham Radio Operator (call sign)                                                                          Resources                                              Yes

CB Radio Operator                                                                                               Active Well

Seamstress/Tailor                                                                                                Portable Water Pump

School Teacher                                                                                                      Portable Generator

Machinist                                                                                                                Portable Heater (fuel type)

                                                                                                                                    Jack Hammer

Construction Skills                                                                                              Air Compressor

Handyman                                                                                                             Come-A-Long/Winch                           

General Construction                                                                                          Chain Saw

Cabinets/Furniture                                                                                              Tent(s) – sleep how many

Carpet Layer                                                                                                           Lantern(s)

Engineer (type)                                                                                                      Back-Hoe/Bulldozer

Finish Carpenter                                                                                                   Snow Plow

Framing                                                                                                                   Pick-Up Truck

Glazier                                                                                                                     4x4

HVAC                                                                                                                       Flat Bed Truck

Heavy Equipment Operator                                                                              Camper

Landscaping                                                                                                          Mobile Home

Painter                                                                                                                     ATV

Locksmith                                                                                                               Medical Supplies

Plumber                                                                                                                  Cribbing Material/Bars

Roofing                                                                                                                   Ham Radio

Sheetrock                                                                                                               FRS Radio