Community Resource Survey - Sample

EAST RIDGE ELEMENTARY
SCHOOL EMERGENCY SURVEY FORM

Name______________________________________

Address____________________________________ I live within walking distance of the school.

Phone______________________________________ I am available during the day to provide
assistance during an emergency or disaster.
E-Mail_____________________________________

If you wish to participate, please check all appropriate lines and identify who in your household has these skills:

First Aid: Describe
 I'm a doctor. __________ __________________________________________
 I'm a nurse. ___________ __________________________________________
 I'm certified in first aid. ____________ __________________________________________
 I have completed the CERT (Community
Emergency Response Training) program
and I would like to support:


___Medical
___Search & Rescue
___Fire Suppression
___Logistics

Food and Shelter:
 I will serve food and water.
 I will help assemble shelters and toilets.

Care:
 I will be of assistance to children (read, comfort, play)
 I have older children who may be willing to assist others.

Communications:
 I am a Ham Radio Operator and have access to a radio.
 I will help in reuniting parents and children.
 I have walkie-talkies.
 I have additional communication resources.
Describe________________________________

Skills:
Please indicate your working skills from the list below. Remember, in a disaster, you may be asked to put these skills to use.

____Auto Mechanic ____Telephone Repair ____Construction ____Fire Suppression
____Plumbing ____Heavy Equipment ____Social Work ____Engineering: __________
____Electrical ____Survival Training ____Search & Rescue

Resources:
 I have access to heavy duty equipment such as:__________________________________
(pick up or flatbed truck, tow truck, bulldozer, winch, snow plow, other)
 I will help in other ways (clearing rubble, etc.)_____________________________________________
 I have access to fuel. (propane, gasoline, etc.)______________________________________________
 I have access to other items:____________________________________________________________ (lumber, chain saw, wheelbarrow, tools, camping equipment, other)
 I have access to alternate transportation (horse, motorcycle, riding lawnmower with trailer, etc.).
_________________________________________________________________________________