Athens Weather Emergency Community Survey

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Athens Weather Emergency Community Survey

This survey will help us respond to the needs of our community in the event of a natural disaster. Providing information is voluntary, will be held in strict confidentiality, and will never be shared beyond committee members. Thank you in advance for sharing information that will help us better serve the community.

13Questions

1
Your Contact InformationThis information will be used to contact you in case of an emergency.
First Name
Last Name
Email
Home Phone
Cell Phone
Address
2
Emergency Contact
First Name
Last Name
Relationship
Yes
No
Do they have a key to your house?
Email
Home Phone
Cell Phone
3
Do you have a backup power source for electricty?
YESNO
4
Without electricity you have no...
Heat
Phone
Water
Cook Stove
Internet
5
Do you have a medical device that needs electricity?
YESNO
6
Your physical ability to move around is...
Good
Poor
Limited
Homebound
7
Do you need a cooling shelter in extreme heat?
YESNO
8
In an emergency, what medications do you rely on?
Huge
Large
Normal
Small
Ok
Ok
9
Do you rely on medication?This is to follow up with you in an emergency to make sure we help get you the medication you need.
YESNO
10
Anything else we should know about in an emergency?E.g. allergies, medical conditions, etc.
Huge
Large
Normal
Small
Ok
Ok
11
I would be happy to help out if called during an emergency but prefer not to answer the questions below.
Yes, contact me in an emergency
See my responses below
12
Would you be willing to help during an emergency?
YESNO
13
How would you want to help?Check only those you feel comfortable with sharing with us.
Skills
Equipment
Shelter
14
What skills can you contribute?Please explain in the appropriate categories
Medical
Counseling
Cooking
Trades
Radio or Other Communications
Other Skills
15
What equipment would you be willing to share?
Portable Generator
Chain Saw
Plow Truck
Tractor
ATV/Snowmobile
NOAA Weather Alert Radio
Shortwave Radio
Pet Crates
16
What kind of shelter are you willing to supply?
Cooling
Short-term Emergency
Farm Animals
Long-term Displacement
House Animals
17
Limits to your offer to shelter
How many people are you willing to shelter?
Identify any other restrictions you'd like to place on your offer to provide shelter.
18
How many pets would require a shelter?
# of Cats
# of Small Dogs
# of Medium Dogs
# of Big Dogs
# of other pets and animal type
19
LivestockIf you have livestock, please describe which, how many, and if you would need relocating your livestock if a weather emergency occurs.
Huge
Large
Normal
Small
Ok
Ok
Should be Empty:

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