Disaster Questionaire

Baycrest Disaster Preparedness Questionnaire

 

In order to assist the Baycrest Security Committee, a resident of each home in Baycrest is being asked to fill out this questionnaire so that residents of your home can receive assistance and direction in the event of an emergency situation, such as a fire, tornado, wind storm, chemical spill, power outage, mudslide or other natural disaster.  This questionnaire is entirely voluntary.  Copies will be kept by the Secretary of Baycrest, the Security Committee Chair, the Road Patrol Captain and the Pope County Sheriff.

 

  1. List your address.

 

  1. List the names of the people and pets residing in your home.  If any children are minors, list their birthdates.

 

 

 

 

 

  1.  If any resident of your home has special needs (such as oxygen, wheel chair, walker, medicine, CPAP, etc.), please list the special need and indicate how that need can be met.

 

 

 

 

 

 

  1.  List all phone numbers where you can be reached.

 

 

 

  1. If you are not a year-round resident, list other addresses and phone numbers where you can be reached.

 

 

  1.  Are you willing to share any of the following special skills if there is an emergency?  (Circle any that apply.)  Doctor    Nurse   Other medical     EMT    First Aid    CPR    Plumbing     Electrical    Law enforcement    Military   Firefighter    Veterinary    Tree removal    Child care    Counseling  Other (list)

 

 

  1.   Do you have any of the following tools and equipment that you would be willing to provide in an emergency?  (Circle any that apply.)     Chain saw     Generator      ATV      Pickup      Van      Trailer     Tall ladder      Golf Cart

 

 

  1.  Are you willing to provide emergency housing?     Yes      No

 

 

  1.  If anyone at Baycrest has a key to your home or knows where one is, please list their name and address and phone numbers.

 

 

  1.  If you are unable to communicate or unable to be reached, list the name, relationship, and phone numbers of a person or persons you would like to be contacted.

 

 

 

 

 

 

 

  1.  List the exact location on your property of any hazardous material such as propane tanks or gas cans.  List where any home heating propane tank is located (above or below ground).