1.) How well prepared are you and your family for a large scale disaster or emergency?
      Completely prepared  Mostly prepared  Somewhat prepared  Not very prepared
      Not at all prepared  Don’t know
 
2.) In an emergency, what is your main way to contact family and friends? (choose one)
     Regular home phone  Cell phone  Email  Pager   2-way radio
     Designated meeting place  Other  Don’t know

3.) I have an emergency kit at (check all that apply):
     Home  Work  School  Car  Do not have one

4.) Check off the items that you have at home to build your emergency kit.
     Food  Water  Clothes  Cash and copy of important documents  Flashlight
     First aid kit  Extra medicine  Portable radio  Tools (wrench, whistle)
     Toiletries (soap, garbage bag, baby wipes, sanitation products)

5.) If you don’t have an emergency kit, are you be planning on building one in the near future?
      Yes No Don’t know
 
       If yes, when? 1 month   3-6 months    1 year     Don’t know

6.) Ethnicity (choose one)
      White   African American   Hispanic   Russian   Armenian   Arab   Persian
      Chinese   Korean   Vietnamese   Cambodian   Filipino 
        Other:

7.) Age (choose one)
      15-24   25-34   35-44   45-55    56+

8.) Gender (choose one)
      Male   Female

                                                          Please be patient while form is submitted