Family Preparedness Questionnaire

Family Preparedness Questionnaire

Water: If city water were contaminated or water lines were broken, would you have water to drink and cook with?

Assuming a minimum of 1 gallon of water per person per day, do you have enough water stored for:

____ 1 day____ 3 days____ 1 week____ 2 weeks or more

Do you have emergency water stored in your cars? ______

Do you have emergency water stored at work? ______

Do you have the ability to filter water for emergency use? ______

Are you interested in learning more about water storage? ______

Fuel: If the electricity were out for more than 24 hours, what would you do for light, cooking, and heat?

Do you have emergency candles? ______Matches? ______

Do you have flashlights for each person in your family? ______

Do you have extra batteries for those flashlights? ______Extra batteries for:

____ 1 day____ 3 days____ 1 week____ 2 weeks or more

Do you have light sticks for each person in your family?

____ 1 day____ 3 days____ 1 week____ 2 weeks or more

Do you have lanterns? ______Extra fuel for lanterns for:

____ 1 day____ 3 days____ 1 week____ 2 weeks or more

Do you have a camping stove or BBQ? ______Enoughfuel for the stove/BBQ for:

____ 1 day____ 3 days____ 1 week____ 2 weeks or more

Do you have fuel to keep your family warm for:

____ 1 day____ 3 days____ 1 week____ 2 weeks or more

Do you have provisions for light and warmth stored in your cars? ______

Do you have provisions for light and warmth stored at your workplace? ______

Food: If unable to go to the store, would you have enough food & other necessities to provide for your family & neighbors as President Green has counseled us?

Were you unable to go to the store, do you have enough food for your family for:

____ 3 days____ 1 week____ 1 month____ 3 months or more

Were you unable to go to the store, do you have enough food for your pet(s) for:

____ 1 day____ 3 days____ 1 week____ 1 month

Were you unable to go to the store, do you have enough food for your neighbors for:

____ 3 days____ 1 week____ 1 month____ 3 months or more

72 Hour Kits:If asked to evacuate on a moment’s notice do you have a 72 hour kit?

Ifasked to evacuate on a moment’s notice, do you have a 72 hour kit for all the members of your family:

____ at home____ in the car____ at work

Do you carry a list of medications and dosages? ______

Do you have copies of your prescriptions in your emergency kit? ______

Do you have an emergency supply ofmedicine for your family for:

____ 1 day____ 3 days____ 1 week____ 2 weeks or more

Were you asked to evacuate on a moment’s notice, do you have enough food for your pet(s) for:

____ 1 day____ 3 days____ 1 week

Does your family know who to call or where to go in case of an area emergency when family members are separated? ______

Does everyone know an “in the area” number to call? ______

Does everyone know an “out of area” number to call? ______

Misc. Preparation: Are you prepared for various emergencies that might strike your family?

Have you & your family discussed what to do in case of fire? ______

Have you had a family fire drill recently? ______

Have you changed the batteries in your smoke alarms in the last 9 months? ______

Do you know how to shut off the gas, electricity, and water if needed? ______

Do you know what to do in case of a poisoning? ______

If you were sick or disabled and in the hospital, do you have a durable power of attorney so that someone you trust can speak for you if you are unable to speak for yourself? _____

If someone had a heart attack, do you know how to administer CPR? _____

Do you have a general knowledge of first aid? _____

If you were in an accident and were unable to tell emergency personnel who to call, do you have three emergency contact numbers in your cell phone? (ICE - In Case of Emergency) ______

If there were an environmental or airborne disaster would you know how to seal off a place in your home? ______

Do you have a designated place in your home and the necessary materials? ______

Are you prepared to take care of all special needs in your family? (ie. age, health, pets, etc.) ______

Financial Preparedness: Financial emergencies are a reality. Are you prepared to face financial challenges that may affect you and your family?

If you lost your job, do you have the skills needed to find another one? _____

Do you know how to put together a resume? _____

Do you have effective interviewing skills? _____

Do you have a savings plan or financial plan for tough financial times? ______

Will you have the money to send your children to college or on a mission? ______

Do you need to know about available scholarships, etc.? ______

Do you children know how two save and spend money wisely? ______

In case your spouse dies, do you know where your important documents are? _____Were you unable to go to the store, do you have enough food for your pet(s) for:

____ 1 day____ 3 days____ 1 week____ 1 month

Do you know important passwords? _____

Do each of you have a will or family trust? _____

Are you aware that by properly structuring your financial affairs your heirs need not pay inheritance taxes? _____

Do you know what to do to prevent identity theft? _____

Do you know what to do if you are a victim of identity theft? _____

If there is a need for long-term care, do you have the means and know how to arrange for this? _____

Family Preparedness Response

Family Name (optional): ______

Would like more information in the following areas:

______

Am willing/able to help others with preparations in the following areas (please explain):

Emergency Response: ______

______

First Aid: ______

______

Food Storage: ______

______

72 Hour Kits: ______

______

Communication: ______

______

Financial Preparation: ______

______

Estate Planning: ______

______

Employment Development: ______

______