Emergency Preparedness Questionnaire
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1. How concerned are you that the following emergency/disaster will affect our community?

	Not Concerned	Not Very Concerned	Neither Concerned nor Unconcerned	Somewhat Concerned	Very Concerned
Criminal Activity	*How concerned are you that the following emergency/disaster will affect our community? Criminal Activity Not Concerned	Criminal Activity Not Very Concerned	Criminal Activity Neither Concerned nor Unconcerned	Criminal Activity Somewhat Concerned	Criminal Activity Very Concerned
Cyber Security Issues	Cyber Security Issues Not Concerned	Cyber Security Issues Not Very Concerned	Cyber Security Issues Neither Concerned nor Unconcerned	Cyber Security Issues Somewhat Concerned	Cyber Security Issues Very Concerned
Earthquake	Earthquake Not Concerned	Earthquake Not Very Concerned	Earthquake Neither Concerned nor Unconcerned	Earthquake Somewhat Concerned	Earthquake Very Concerned
Flood	Flood Not Concerned	Flood Not Very Concerned	Flood Neither Concerned nor Unconcerned	Flood Somewhat Concerned	Flood Very Concerned
Hazardous Materials Incident	Hazardous Materials Incident Not Concerned	Hazardous Materials Incident Not Very Concerned	Hazardous Materials Incident Neither Concerned nor Unconcerned	Hazardous Materials Incident Somewhat Concerned	Hazardous Materials Incident Very Concerned
Household Fire	Household Fire Not Concerned	Household Fire Not Very Concerned	Household Fire Neither Concerned nor Unconcerned	Household Fire Somewhat Concerned	Household Fire Very Concerned
Public Health Emergency	Public Health Emergency Not Concerned	Public Health Emergency Not Very Concerned	Public Health Emergency Neither Concerned nor Unconcerned	Public Health Emergency Somewhat Concerned	Public Health Emergency Very Concerned
Severe Thunderstorm	Severe Thunderstorm Not Concerned	Severe Thunderstorm Not Very Concerned	Severe Thunderstorm Neither Concerned nor Unconcerned	Severe Thunderstorm Somewhat Concerned	Severe Thunderstorm Very Concerned
Snow Storm	Snow Storm Not Concerned	Snow Storm Not Very Concerned	Snow Storm Neither Concerned nor Unconcerned	Snow Storm Somewhat Concerned	Snow Storm Very Concerned
Terrorist Activity	Terrorist Activity Not Concerned	Terrorist Activity Not Very Concerned	Terrorist Activity Neither Concerned nor Unconcerned	Terrorist Activity Somewhat Concerned	Terrorist Activity Very Concerned
Wildfire	Wildfire Not Concerned	Wildfire Not Very Concerned	Wildfire Neither Concerned nor Unconcerned	Wildfire Somewhat Concerned	Wildfire Very Concerned

2. What steps have you taken to prepare for the types of emergencies and disasters that might occur in our community?

	Unable To Do	Have Not Done	Plan To Do	Have Done
Collected preparedness information	*What steps have you taken to prepare for the types of emergencies and disasters that might occur in our community? Collected preparedness information Unable To Do	Collected preparedness information Have Not Done	Collected preparedness information Plan To Do	Collected preparedness information Have Done
Attended meetings dealing with emergency preparedness	Attended meetings dealing with emergency preparedness Unable To Do	Attended meetings dealing with emergency preparedness Have Not Done	Attended meetings dealing with emergency preparedness Plan To Do	Attended meetings dealing with emergency preparedness Have Done
Prepared and discussed family emergency plan	Prepared and discussed family emergency plan Unable To Do	Prepared and discussed family emergency plan Have Not Done	Prepared and discussed family emergency plan Plan To Do	Prepared and discussed family emergency plan Have Done
Have takenspecial training (First Aid, CPR, CERT, etc.)	Have takenspecial training (First Aid, CPR, CERT, etc.) Unable To Do	Have takenspecial training (First Aid, CPR, CERT, etc.) Have Not Done	Have takenspecial training (First Aid, CPR, CERT, etc.) Plan To Do	Have takenspecial training (First Aid, CPR, CERT, etc.) Have Done
Signed up for/follow emergency information and alert systems ("Beckley Ready" Facebook & Twitter, Nixle etc.)	Signed up for/follow emergency information and alert systems ("Beckley Ready" Facebook & Twitter, Nixle etc.) Unable To Do	Signed up for/follow emergency information and alert systems ("Beckley Ready" Facebook & Twitter, Nixle etc.) Have Not Done	Signed up for/follow emergency information and alert systems ("Beckley Ready" Facebook & Twitter, Nixle etc.) Plan To Do	Signed up for/follow emergency information and alert systems ("Beckley Ready" Facebook & Twitter, Nixle etc.) Have Done
Assembled a "Disaster Supply Kit"	Assembled a "Disaster Supply Kit" Unable To Do	Assembled a "Disaster Supply Kit" Have Not Done	Assembled a "Disaster Supply Kit" Plan To Do	Assembled a "Disaster Supply Kit" Have Done

3. Concerning preparedness supplies and actions, which of these have you addressed?

4. Preferred manner(s) in which to receive preparedness information.

	Check All That Apply
Fact sheet/brochure	*Preferred manner(s) in which to receive preparedness information. Fact sheet/brochure Check All That Apply
Public workshops/meetings	Public workshops/meetings Check All That Apply
Radio	Radio Check All That Apply
Television	Television Check All That Apply
Newspaper	Newspaper Check All That Apply
Internet (website, e-mail, etc.)	Internet (website, e-mail, etc.) Check All That Apply
Social media (Facebook, Twitter, etc.)	Social media (Facebook, Twitter, etc.) Check All That Apply
Outdoor advertisement (e.g. billboards)	Outdoor advertisement (e.g. billboards) Check All That Apply

Other (please specify)

5. Preferred manner(s) in which to receive ongoing emergency/disaster information.

	Check All That Apply
Radio	*Preferred manner(s) in which to receive ongoing emergency/disaster information. Radio Check All That Apply
Television	Television Check All That Apply
Newspaper	Newspaper Check All That Apply
Internet (website, e-mail, etc.)	Internet (website, e-mail, etc.) Check All That Apply
Notification services (e.g. Nixle)	Notification services (e.g. Nixle) Check All That Apply
Social media (Facebook, Twitter, etc.)	Social media (Facebook, Twitter, etc.) Check All That Apply
Outdoor advertisement (e.g. sign boards)	Outdoor advertisement (e.g. sign boards) Check All That Apply

Other (please specify)

6. What information would you like to know more about?

	Check All That Apply
General emergency preparedness	*What information would you like to know more about? General emergency preparedness Check All That Apply
Formulating a Disaster Kit	Formulating a Disaster Kit Check All That Apply
Emergency information concerning seniors	Emergency information concerning seniors Check All That Apply
Emergency information concerning pets	Emergency information concerning pets Check All That Apply
Emergency information concerning those with special needs	Emergency information concerning those with special needs Check All That Apply
Emergency information for businesses/organizations	Emergency information for businesses/organizations Check All That Apply

Other (please specify)

7. Please select your age.

	Select One
Under 20	*Please select your age. Under 20 Select One
20-29	20-29 Select One
30-39	30-39 Select One
40-49	40-49 Select One
50-59	50-59 Select One
60-69	60-69 Select One
70 or older	70 or older Select One

8. Please select your gender.

	Select One
Male	*Please select your gender. Male Select One
Female	Female Select One

9. Please use this space if you have additional thoughts and/or recommendations. Also, please provide applicable information if you would like to be contacted.

Please use this space if you have additional thoughts and/or recommendations. Also, please provide applicable information if you would like to be contacted.

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	Yes	No	In The Process	Not Applicable
Water, one gallon of water per person per day for at least three days	*Concerning preparedness supplies and actions, which of these have you addressed? Water, one gallon of water per person per day for at least three days Yes	Water, one gallon of water per person per day for at least three days No	Water, one gallon of water per person per day for at least three days In The Process	Water, one gallon of water per person per day for at least three days Not Applicable
Food, at least a three-day supply of non-perishable food	Food, at least a three-day supply of non-perishable food Yes	Food, at least a three-day supply of non-perishable food No	Food, at least a three-day supply of non-perishable food In The Process	Food, at least a three-day supply of non-perishable food Not Applicable
Battery-powered(with extra batteries) or hand crank radio	Battery-powered(with extra batteries) or hand crank radio Yes	Battery-powered(with extra batteries) or hand crank radio No	Battery-powered(with extra batteries) or hand crank radio In The Process	Battery-powered(with extra batteries) or hand crank radio Not Applicable
Flashlight and extra batteries	Flashlight and extra batteries Yes	Flashlight and extra batteries No	Flashlight and extra batteries In The Process	Flashlight and extra batteries Not Applicable
First aid kit	First aid kit Yes	First aid kit No	First aid kit In The Process	First aid kit Not Applicable
Whistle to signal for help	Whistle to signal for help Yes	Whistle to signal for help No	Whistle to signal for help In The Process	Whistle to signal for help Not Applicable
Sanitation and hygiene items	Sanitation and hygiene items Yes	Sanitation and hygiene items No	Sanitation and hygiene items In The Process	Sanitation and hygiene items Not Applicable
Wrench or pliers to turn off utilities	Wrench or pliers to turn off utilities Yes	Wrench or pliers to turn off utilities No	Wrench or pliers to turn off utilities In The Process	Wrench or pliers to turn off utilities Not Applicable
Manual can opener for food	Manual can opener for food Yes	Manual can opener for food No	Manual can opener for food In The Process	Manual can opener for food Not Applicable
Cell phone with chargers	Cell phone with chargers Yes	Cell phone with chargers No	Cell phone with chargers In The Process	Cell phone with chargers Not Applicable
Cashes and coins	Cashes and coins Yes	Cashes and coins No	Cashes and coins In The Process	Cashes and coins Not Applicable
Regularly used medications	Regularly used medications Yes	Regularly used medications No	Regularly used medications In The Process	Regularly used medications Not Applicable
Extra set of house and car keys	Extra set of house and car keys Yes	Extra set of house and car keys No	Extra set of house and car keys In The Process	Extra set of house and car keys Not Applicable
Matches in waterproof container	Matches in waterproof container Yes	Matches in waterproof container No	Matches in waterproof container In The Process	Matches in waterproof container Not Applicable
Supplies specific for infants	Supplies specific for infants Yes	Supplies specific for infants No	Supplies specific for infants In The Process	Supplies specific for infants Not Applicable
Supplies specific for pets	Supplies specific for pets Yes	Supplies specific for pets No	Supplies specific for pets In The Process	Supplies specific for pets Not Applicable
Supplies specific for seniors, special needs, or those with allegies	Supplies specific for seniors, special needs, or those with allegies Yes	Supplies specific for seniors, special needs, or those with allegies No	Supplies specific for seniors, special needs, or those with allegies In The Process	Supplies specific for seniors, special needs, or those with allegies Not Applicable
Generator for emergency power	Generator for emergency power Yes	Generator for emergency power No	Generator for emergency power In The Process	Generator for emergency power Not Applicable
Determined emergency out of town contact	Determined emergency out of town contact Yes	Determined emergency out of town contact No	Determined emergency out of town contact In The Process	Determined emergency out of town contact Not Applicable
Formulated an Emergency Operations Plan	Formulated an Emergency Operations Plan Yes	Formulated an Emergency Operations Plan No	Formulated an Emergency Operations Plan In The Process	Formulated an Emergency Operations Plan Not Applicable
Formulated an Continuity of Operations Plan	Formulated an Continuity of Operations Plan Yes	Formulated an Continuity of Operations Plan No	Formulated an Continuity of Operations Plan In The Process	Formulated an Continuity of Operations Plan Not Applicable
Detrmined adequate insurance coverage	Detrmined adequate insurance coverage Yes	Detrmined adequate insurance coverage No	Detrmined adequate insurance coverage In The Process	Detrmined adequate insurance coverage Not Applicable

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Emergency Preparedness Questionnaire
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