Disaster Preparedness Questionnaire
Personal Information
Name
First Name
Last Name
Email
example@example.com
Would you like to be added to the GOCHA mailing list?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Mobile Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Emergency Contact Info
Emergency Contact
First Name
Last Name
Phone Number
-
Area Code
Phone Number
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Family Data
Number of people living in household
Adults
Seniors
Minors
Disabled
Specify Condition
Languages
Primary Language Spoken
Other Languages Spoken
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Skills
Job Skills in Family
Hobby Skills in Family
Other Skills
Electrical
Plumbing
Carpentry
Construction
Other
Licensed Medical Professionals
MD
RN/LVN
Other
Training
First Aid
CPR
CERT
Fire Fighting
Damage Assessment
Other
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Material
Resources
SUV (or other 4-wheel drive vehicle
Yes
No
Recreational Vehicle (in canyon)
Yes
No
Ham Radio
Yes
No
Ham Radio Code
Number of Family Radios (walkie-talkies)
Number of Fire Extinguishers
Fire Extinguisher Capacity
Number of Flashlights (with batteries)
Do You Have a Pool?
Yes
No
Spa
Yes
No
Gasoline/Battery Operated Pool Pump
Yes
No
Number of Water Hoses
Tents
Yes
No
Capacity (people)
Tool Shed/ Playhouse, Etc.
Yes
No
Portable Toilet
Yes
No
Power Tools
Yes
No
Type of Tools
Alternate Cooking Source (bbq, camp stove, etc.)
Yes
No
First Aid Kit
Yes
No
Number of Bicycles
Number of Bicycle or Safety Helmets
Other Useful Supplies or Resources
Utility Shut-off Locations
Draw the outline of your home with location of utilities marked (can be very rough)
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Pets
Do you have pets?
Yes
No
Dogs
Cats
Other
Please specify type and number
Add the type and names of each pet in your household.
Location of Pet Food (1 week supply)
Location & Dosage of Medications
Name and address of neighbor(s) you trust to take care of your pet
Sign here to authorize a volunteer to reach and care for your pets
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Volunteer Opportunities
I would like to become a volunteer in my zone
I would like to help with emergency communications
I would like to help at Headquarters
Newsletter
Yes, subscribe me to the GOCHA mailing list.
Submit
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