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1. Have you ever been a victim of a disaster?
 
Yes
 
No
 
Your age at the time of disaster
 

 
 
2. I believe that disaster preparedness is important for individuals and families?
Strongly Disagree Disagree Undecided Agree Strongly Agree
 
 
 
How would you rate the disaster risk level of your community?
Low Medium High
 
 
 
3. How would you rate your disaster preparedness level?
Poor Below Average Average Good Excellent
 
 
 
 
4. Have you had any disaster preparedness training?
 
First Aid
 
CPR
 
CERT
 
Red Cross
 
HAZMAT
 
Fire fighting
 
Online course
 
Other
 

 
 
 
5. Have you ever had an occasion to use your disaster preparedness training?
 
Yes
 
No
 
I do not have any disaster preparedness training.
 
 
 
6. How long could you and your family survive if you could not leave your home and you lost all utilities?
 
24 hours
 
36 hours
 
48 hours
 
60 hours
 
72 hours
 
Other
 
 
 
 
7. Do you currently have a disaster preparedness kit in your home?
 
Yes
 
Somewhat
 
No

 
 
 
8. What is your primary reason for creating a preparedness kit?
 
To take care of my family
 
To help my neighbors
 
To help my community
 
I do not have a preparedness kit.
 
Other
 
 
 
 
9. Have you ever used your kit for a disaster or accident or incident?
 
Yes
 
No
 
I do not have a kit.
 
 
 
10. Which of the following items are currently included in your disaster preparedness kit and plan?
 
I do not have a kit.
 
Water
 
Food
 
Medications
 
Personal hygene items
 
Copies of important documents
 
Baby supplies (if applicable)
 
Pet supplies (if applicable)
 
Flashlight
 
Radio
 
Batteries
 
Out of state contact person
 
Back up generator
 
Back up heat source
 
First aid kit
 
Can opener
 
Whistle
 
Cash
 
Sleeping bag or blankets
 
Extra clothing
 
Chlorine bleach
 
Mess kit or disposable items

 
 
11. If you do not already have a preparedness kit, how likely are these options to influence you to create one?
Not at all likely Not very likely Somewhat likely Very likely N/A
Requested by children/family
Advertisement on TV
Information pamplet in the mail
Community or church presentation
Availablility of discounted kits
News story of a nearby disaster
A tax refund on purchased kits
 
 
 
12. What is your gender?
 
Female
 
Male
 
 
13. Please indicate your age bracket
20-29 30-39 40-49 50-59 60-69
 
 
 
14. Please enter your zip code
 
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