Natural Disaster Survey for Seniors

 
The Nez Perce Tribe is strategic planning to better serve Nez Perce Senior Citizens 55 years and over in the event of a natural disaster. The information collected with this survey is to identify emergent areas and households, in events such as floods, extended power outage, tornado, etc.

It is the intent and goal of the Nez Perce Tribe to know who needs immediate assistance upon disaster.
1. Name
2. Age
Age
3. Do you have a disability that limits your mobility?
4. Do use any of the following for mobility (select all that apply)
5. Address
6. Length of time at current address
7. How do you primarily heat your home?
8. Do you have transportation?
9. Is your transportation reliable?
10. Source of Water Supply
11. If you are ill or hurt who cares for you? (Select all that apply)
12. Do you have a landline telephone in your home?
13. Do you have a cell phone?
14. Is there cell phone reception at your home?
15. Are you on portable oxygen?
16. Are you hard of hearing or use hearing aid(s)?