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* 1. Please select your preferred language.

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* 2. What is your age?

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* 3. Are you of Hispanic, Latino, or Spanish origin?

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* 4. I am...

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* 5. What type of disability/disabilities do you have?

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* 6. Do you live with anyone?

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* 7. What is your current level of preparedness for an emergency?

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* 8. What types of emergencies are the most concerning to you? Select all that apply.

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* 9. Have you ever had an emergency that disrupted your day-to-day activities?

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* 10. What type(s) of emergencies have you or your family experienced? Select all that apply.

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* 11. What have you done to prepare for an emergency in the last year? Select all that apply.

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* 12. Does your emergency plan include any of the following? Select all that apply.

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* 13. Are you aware of the emergency plan(s) for your school(s), workplace(s) or community center(s)?

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* 14. Do you have a service animal?

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* 15. How do you receive alerts and warnings for emergencies? Select all that apply.

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* 16. Do you use any of the following mobility devices or assistive technology devices? Select all that apply.

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* 17. What kind of transportation do you use? Check all that apply

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* 18. Do you own any solar-powered items (such as radios, flashlights, etc.)?

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* 19. In an emergency, which of the following are you most concerned about going without? Check all that apply

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* 20. Listening Session

The Arc Lane County would like to host a future listening session to discuss emergency preparedness in April and May 2024. We will pay you a stipend in the form of a gift card for your participation in a 2-hour listening session.


Would you be willing to participate in a listening session to discuss emergency preparedness?

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* 21. The format for the listening session is still being decided. What is your preference?

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* 22. Do you have a preference on the time of day to participate in a 2-hour discussion?

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* 23. Do you have any access needs or accommodations?

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* 24. Please type your name

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* 25. Please provide your email.

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* 26. Please provide your phone number.

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* 27. To enter the raffle, please enter your name.

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* 28. Please provide either your email or telephone number so we may contact you if your name is drawn in the raffle.

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