Do you or any person(s) in your household have medical training?

 Doctor  Nurse  Basic EMT  Other   

Is anyone licensed or certified as a:

Building Contractor  Building Inspector   Carpenter      Electrician        
General Contractor   Structural Engineer  

Is anyone trained in:

First Aid   Disaster Preparedness   Hazardous Materials  Heavy Equipment Operation

Shelter Management   Red Cross Operation   Search & Rescue            

Number of persons and what specific field(s)

Do you have access to any specialized equipment that may be used during

an emergency, or for rescue operations?

Wheel Drive/Pickup truck
Flat Bed trailer
Hoists/Jacks
Construction Equipment
Generators
Other

Do you have at or near your home a:

Generator
Large Fuel Supply
Heavy Construction tools

If yes, what type:

Does your household have access to any special communications equipment?

2-way Radio       Satellite Phones  Ham Radio         UHF Radio       

If yes, would you volunteer your services to operate it in an emergency?  Yes  No  

Are you or household members interested in Neighborhood Watch and/or CERT

(Community Emergency Response Training) Training?

Yes  No   

If you live in a multi-unit building, does your complex have a disaster plan?

          Yes  No  

If no, are you interested in developing one?

Yes  No   

What is the status of your basic household preparedness?

     Drinking Water (2 gallons per person per day)

    Non-Perishable Food (72 hour supply per person minimum)

    Out-Of-State Contact

    Shelter Supplies (Blankets, tents, battery/solar camp lights)

    Flashlights and extra batteries

    Fire Extinguisher (ABC multipurpose type)

    Battery Powered Radio

    Heavy socks, shoes, glove and clothing

   Sanitation Materials (bucket, trash bags, water, toweling, etc.)

    Important Documents and account information

    Pet supplies (food, water, cages)

    Prescriptions, glasses, hygiene products

    Tools and equipment (shovel, crow bar, etc.)

    Cash

Do you have any "special needs" that emergency workers should be aware of

(mobility issues, specialized equipment such as oxygen supply, wheelchairs, etc.)?

If so, what are they:

Are you unable to leave  your home on your own, or without assistance?

Yes  No   

Name  

Address   

Telephone Number  Work     Home  

                                        Cell

Commute Time to Hermosa Beach From Work: 

Hours Worked 

Hours Normally At Home 

If a second member of the household is also responding, please

complete this part of the form:

Name  

Address   

Telephone Number  Work     Home  

                                        Cell

Commute Time to Hermosa Beach From Work: 

Hours Worked 

Hours Normally At Home