Name

Age

Email

Phone number

Address

What climate hazards have you experienced in your area in the past 5 years?

(Check all that apply)

• Extreme heatwaves

• Flooding

• Drought

• Wildfires

How often do these climate events occur in your area?

• Rarely

• Occasionally

• Frequently

Do you have any medical conditions that may be worsened by climate events?

If yes, please specify

Are you reliant on resources or utilities (e.g., electricity, water) that are often disrupted by extreme weather events?

What types of emergency resources do you currently have access to?

• Generators

• First aid kits

• Stored water

How do you currently prepare for a climate-related emergency?

• Creating a plan

• Storing supplies

• Staying informed

What additional resources or support would help you feel more prepared for a climate emergency?

• Community programs

• Training

• Financial assistance