Date

Please enter the date you are completing this form.

Name

Please enter your full name, including your middle name if applicable.

Email

Please enter your email address for contact purposes.

Do you have a family communication plan for emergencies?

• Yes

• No

Have you received any emergency preparedness training?

• Yes

• No

Do you have an emergency plan in place?

• Yes

• No

Do you have an emergency preparedness kit?

• Fully Stocked Kit

• Partially Stocked Kit

• No Kit

How often do you practice emergency drills?

Select the frequency that best describes your practice.

Additional Comments

Please share any additional information or suggestions about emergency preparedness.