Old Mountain View Neighborhood Association
CERT
Community Emergency Response Team

Print out this form and mail it to the address below

EMERGENCY INFORMATION SURVEY

December, 2001

Since a major earthquake is likely to leave our neighborhood without public services for several days or longer, OMVNA CERT is using this survey to collect important information on local needs and resources. All information will be kept confidential.

Please return the completed form to: Aaron Grossman, 234 W. Dana Street, Mountain View, CA 94041

Questions? Call Aaron at 650 969-4031. We also need volunteers to help organize the team.

Household Name(s) ______________________________________________________
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Street address _________________________________________________________________

Home phone __________________________ Email __________________________________

Best way to contact you(circle one): phone / mail / email

Out of State emergency contact (name/phone):__________________________________________
(out of state calls may be more likely to get through in an emergency)

Address________________________________________________________________________

SPECIAL EMERGENCY NEEDS

Medical Oxygen __ Insulin __ Medication cold-storage __
Power for medical equipment __ Other _____________________________

Mobility Bed-ridden __ Wheelchair __ Walker/cane __ Blind __
Other: __________________________________________

Communication
Difficulty with English - specify preferred language:___________________

Deaf __ Other ________________________________________________

Pets (specify) _________________________________________________________________

SKILLS YOU CAN SHARE

Skills (please specify)

Language interpreter (language) ___________________________________________________

Amateur radio license ___________________________________________________________

Public safety/security training or experience __________________________________________

Search and rescue ______________________________________________________________

Heavy equipment operation _______________________________________________________

Damage assessment _____________________________________________________________

Medical or First Aid training ______________________________________________________

CERT training _________________________________________________________________

Counseling ____________________________________________________________________

Shelter manager _______________________________________________________________

Other ________________________________________________________________________

Interested in taking CERT training from the City of Mountain View __________________

Willing to be a street organizer now (need two per block-length of street)_______________

MATERIALS AND RESOURCES YOU CAN SHARE

Shelter: large tent(s) __ Clear garage __ RV __ Other _______________________________

Radios: Ham __ CB __ Two-way __ Other _______________________________________

Power generators ___________________________________________________________

Heavy equipment ____________________________________________________________

Stretcher-capable vehicle(s) ___________________________________________________

Rescue tools: Pry bar __ Sledge __ Chain saw __ Other _____________________________

Other ________________________________________________________________________

INFORMATION TO SHARE

As you have worked on your own household emergency preparation (so you can do without outside food, water, medical supplies, heat, and electricity for up to three days), have you found out anything that would be useful to others in the neighborhood? Please summarize your discoveries here, and we will get back to you for more details, so we can share them through the Newsletter (anonymously, if you would like).

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Last updated: 12/01/01