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(Please fill out each of the three forms, including the
Family
Registry Form and the Special Skills/Equipment/Resources
Form)
Name: ___________________________________
Phone: __________________________________
Address: ________________________________
e-mail (if available): _________________________
IF ENGLISH IS YOUR SECOND LANGUAGE, DO YOU NEED HELP
TRANSLATING
THIS QUESTIONNAIRE AND OTHER EMERGENCY PREPARATION
MATERIALS?
YES___
NATIVE LANGUAGE:_______________________
IS YOUR HOUSEHOLD PREPARED?
1. Is your house/apartment building bolted and
sheerwalled?
YES___
NO___
NOT SURE___
2. Is your house/apartment building made of unreinforced
masonry?
YES___
NO___
NOT SURE___
3. Is your waterheater strapped down (potential fire
hazard)?
YES___
NO___
NOT SURE___
4. Are your heavy furniture items (such as book shelves)
secured
(bolted to studs in the wall)?
YES___
NO___
5. Do you have at least a 3-day supply of water (plan on one
gallon
per person, per day)
YES___
NO___
6. Do you have an emergency food supply?
YES___
NO___
7. Do you have a first aid kit?
YES___
NO___
8. Do you want help in evaluating/securing your home?
YES___
NO___
FOR APARTMENT DWELLERS (WITH MORE THAN 2 UNITS)
1. Are you willing to serve as a contact person for your
apartment
building?
YES___
NO___
2. Name of Landlord:____________________________________
Landlord's Address:__________________________________
__________________________________
Landlord's Phone Number: ___________________________
DEVELOPING A NEIGHBORHOOD EMERGENCY PLAN
1. Are you willing to attend any planning meetings scheduled
in the
future?
YES___
NO___
NOT ABLE TO NOW, BUT KEEP ME INFORMED___
2. Are you interested in joining any of the following
earthquake
response teams? (check one--see attached pages describing
team
responsibilities)
Damage Assessment___
Communications___
Sheltering and Special Needs___
Hazard Reduction___
Casualty Collection___
Search and Rescue___
3. Were you unable to attend the CORE training, but
interested in
receiving copies of training materials?
YES___
NO___
4. Would you like to attend a CORE training in the
future?
YES___
NO___
MAYBE___
5. Do you have space in a structurally sound garage or other
unit
that you would be willing to make available as our
neighborhood
command post, a place where we can store central supplies,
and
gather after an earthquake and organize response teams?
YES___
NO___
MAYBE___
6. Are you willing/able to make a financial contribution
($5-25)
towards purchasing tools and supplies that would serve the
entire
neighborhood in a disaster? (for example, ham radio,
generator,
hard hats, radios, flashlights, bulletin boards, walkie
talkies)
YES___
NO___
MAYBE LATER___
7. Are you willing to assist a neighbor in
evaluating/securing
his/her home (for example, evaluate state of foundation,
help bolt
book cases to the studs in walls, review safety measures,
etc.)
YES___
NO___
MAYBE___
8. Are you willing to serve as a "disaster buddy" to a
neighbor
with special needs (for example, someone with a physical
disability)?
YES___
NO___
MAYBE___
9. Would you like to be included in a phone tree to be
notified
about special events?
YES___
NO___
10. Would you be willing to help make phone calls and/or
distribute
notices about special events and planning meetings?
YES___
NO___
ORGANIZING BLOCK PARTIES
During times of distress it is easier to work with friends
and
acquaintances than with strangers. Block parties--aside from
being
a lot of fun (as those who attended the 44th Street block
party
last September can testify)--can help to build friendly
associations that will make preparing for an earthquake a
lot
easier. Please indicate whether you would like to work on
any of
the following committees to plan another block party on 44th
Street
(or on your block):
Publicity___
Food/Decorations___
Entertainment___
Kids Activities___
Check here if you have a special musical talent, and would
be
willing to perform___
GENERAL CONCERNS
Any other concerns you'd like to express:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Copyright City of Oakland 1993
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The neighborhood earthquake committees are still in the
process of forming, so no one is officially "in charge" yet,
but if you have questions or concerns about the
questionnaire or about the emergency plan, please feel free
to contact any of the following people who participated in
the CORE trainings:
44th Street * Sally Thomas, 471-44th (658-9673)
Laura Jackson (601-1580)
Howard Lasseter (601-6729)
Gloria Cobb (428-0827)
45th Street * Tom Wenzel, 416-45th (601-0574)
Patrick Hickey (428-7633)
Webster Street * Cathy Steirn, 4415 Webster (547-3193)
John Goodwin (655-6727)
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