Zeal Monachorum Emergency Plan Survey

Last Name:

First Name:

Title (Dr/Mr/Mrs/Ms/etc):

Address: 

Post Code:

Telephone Number:

Mobile Phone Number:

E-mail Address:

What are the age ranges of your household?

Please put the number in the box next to the range e.g. If you have two children between four and twelve put a “2” in the box.

 

•   3 or under:
•       4 to 12: 
•     13 to 17: 
•     18 to 40: 
•     41 to 65: 
•     66 to 80: 
•  81 or over: 

In what type of property do you live?

•       House:
•         Farm:
•  Bungalow:
•           Flat:
•    Caravan:
•        Other:
•   If "Other" selected then please give details below:

What fuel do you use to cook?

(You may have to tick more than one box)

•      Electricity:
•     Mains Gas:
•   Bottled Gas:
•   Tanked Gas:
•      Solid Fuel:
•                 Oil:

What type of water supply do you have?

(You may have to tick more than one box)

•       Mains:
•         Well:
•  Borehole:
•      Spring:

Do you or your household have urgent medical needs or supplies?

•  Oxygen:
•    Insulin:
•   Other - please specify below:

Are there any members of your household with disabilities?

(Please specify)

Do you or any of your household have any of the following skills?

(You may need to tick more than one box)

•             Medical, Dental or Veterinary Professional:
•                            Nurse, Pharmacist or Paramedic:
•  Fire, Rescue or Military Service in the last 5 years:
•                                                    First Aid training:
•                                                                 Building:
•                                                               Plumbing:
•                                                             Electrician:
•                                                      Gas Installation:
•                                                              Mechanic:
•                                                        HGV Licence:
•                                                      Plant Operator:
•                                                       Administrative:
•                         Computer networking or sysadmin:
•                              WP or general computer usage:
•                                                                Catering:
•                  Radio Operator (Ham/Marine/Military):
•                                        Telephonist/Receptionist:

Do you have any other skills, hobbies or interests that you think may be useful in assisting the community in a major emergency?

(Please specify)

For example - special communications equipment, life saving, survival experience, cross country expertise etc

Do you have any of the following available for emergency use?

(You may need to tick more than one box)

(Note: some compensation for use will be available)

•                                           Tractor:
•                                            Trailer:
•                                  Snow-plough:
•                                     4x4 vehicle:
•                      Lorry or utility vehicle:
•                                     Motorcycle:
•                                            Bicycle:
•                           Mobile water tank:
•                                Portable pump:
•                                                JCB:
•                                      Lifting gear:
•                              Heavy lift cables:
•                                             Winch:
•                                        Generator:
•                                        Chainsaw:
•                    HF or VHF transceiver:
•  PMR (446MHz) or CB transceiver:
•                                Portable heater:
•                                   Gas cylinders:
•                                           Ladders:
•                          Lighting equipment:
•                                  Loudspeakers:
•                      Waterproof tarpaulins:

Do you have any other items which may be useful in an emergency situation?

Is there any other information we should know in the event of an emergency?

(Please specify)

Have you been involved in, or had experience of an emergency before ?

•  Yes:
•   No:

If so what aspects of the planning and preparations went really well?  What items of equipment proved particularly useful?  Please tell us in a few words.

And what did not work well?  What could have made things better?  What items of pieces of equipment which were not available would have been particularly helpful?

Would you be prepared to provide emergency accommodation for a short time to anyone made homeless?

•  Yes:
•   No:

Would you be prepared to become a Neighbourhood Contact?

(One person is needed for each part of the Parish)

•  Yes:
•   No:

Would you be interested in becoming a member of the Emergency Planning Group?

•  Yes:
•   No:

I understand that the data I submit via this web form is unencrypted until it reaches the Parish Council and it is possible (though highly unlikely) that it could be intercepted.  Furthermore, I understand that completion in full or in part of this survey implies that I accept that the Parish Council may store this data in hard copy or electronically under the terms of the Data Protection Act 1998 and in accordance with the Parish Council's Emergency Planning Data Security Protocol

Please press check the form through and press "Submit" when you have completed it.

Note: The "I agree" check box above must be ticked in order for this form to be processed.