The Arc Lane County Survey on Emergency Preparedness
1.
Please select your preferred language.
English
Spanish
2.
What is your age?
Under 18
18-19
20-29
30-39
40-49
50-59
60-69
70-79
80+
Prefer not to answer
3.
Are you of Hispanic, Latino, or Spanish origin?
Yes
No
I Do Not Know
4.
I am...
A person with a disability.
A parent of a person with a disability.
A support professional (PSW, DSP, Job Coach, etc.)
A person with a disability and the parent of a person with a disability.
A person with a disability and a support professional (PSW, DSP, Job Coach, etc.).
A parent of a person with a disability and a support professional (PSW, DSP, Job Coach, etc.).
A person with a disability, that is a parent of a person with a disability, and is a support professional (PSW, DSP, Job Coach, etc.).
5.
What type of disability/disabilities do you have?
6.
Do you live with anyone?
No, I live by myself.
Parent
Child/children under 18 years of age
Spouse or partner
Other family members
Friend or Roommate
Primary Caregiver (Paid)
Primary Caregiver (Unpaid)
7.
What is your current level of preparedness for an emergency?
High: I have a current plan put in place that includes basic supplies, medications, and equipment to meet my daily needs.
Medium: I have discussed my plans and have some basic supplies.
Low: I have some knowledge about preparedness but no specific plan.
I do not feel confident that I am prepared for an emergency situation .
8.
What types of emergencies are the most concerning to you? Select all that apply.
Earthquake
Explosion
Extreme Heat
Flood
Food or Water Contamination
No Water
Home Fire
Evacuation
Pandemic
Power Outage
Wind and Thunder Storms
Wildfire
Snow Storm
Ice Storm
Dam Failure
Don't Know
Other
9.
Have you ever had an emergency that disrupted your day-to-day activities?
Yes
No
I Do Not Know
10.
What type(s) of emergencies have you or your family experienced? Select all that apply.
Earthquake
Explosion
Extreme heat
Flood
Food or water contamination
No water
Home fire
Evacuation
Pandemic
Power outage
Wind and thunderstorms
Wildfire
Snowstorm
Ice storm
Dam failure
Don’t know
Other
11.
What have you done to prepare for an emergency in the last year? Select all that apply.
Made a plan
Created an evacuation route
Learned my evacuation route
Practiced emergency drills
Gathered supplies (food, water, medication, pet supplies)
Planned with neighbors
Protected important documents
Signed up for emergency alerts
Created a household communication plan
Created a check-in plan with support system
Created a shelter in place plan
I do not know
I have no plan
12.
Does your emergency plan include any of the following? Select all that apply.
Checking on your neighbors to make sure they are okay
Information about how to evacuate
Information about where to shelter or a safe place you can stay
A plan for the people living in your house to get in touch with each other
A plan for getting in touch with your support system
I don’t know
I have no plan
13.
Are you aware of the emergency plan(s) for your school(s), workplace(s) or community center(s)?
Yes
No
I Do Not Know
14.
Do you have a service animal?
Service Animal
Guide Dog/Animal
Emotional Support Animal
I Do Not Have a Service Animal
I have a pet that is not a service animal
15.
How do you receive alerts and warnings for emergencies? Select all that apply.
Mobile app
Internet
Email
Face to face (neighbor)
Radio
Social media
Text or telephone call
Television
None of the above
16.
Do you use any of the following mobility devices or assistive technology devices? Select all that apply.
Walker, cane or crutches
Scooter
Manual wheelchair
Power wheelchair
Smart Drive/power assist attachment
Ventilator
Prosthesis
Hearing aid
Cochlear implant
Relay Services
Refreshable Braille display
Screen reader
Screen magnifier
Adapted mouse
Adapted keyboard
Voice control (such as Dragon Naturally Speaking)
Speech to text
Text to speech
Switch devices
Eye gaze
Augmentative and Alternative Communication (AAC)
CPAP with battery back up
I do not use any mobility devices or assistive technology devices.
17.
What kind of transportation do you use? Check all that apply
I drive my own vehicle.
A family member or support person provides transportation for me.
I have my own vehicle that someone else drives.
I use RideSource.
I use public transportation (LTD).
I use a rideshare service (Lyft/Uber/Taxi)
I ride a bicycle or electric scooter.
I walk.
18.
Do you own any solar-powered items (such as radios, flashlights, etc.)?
Yes
No
I do not know
Other
19.
In an emergency, which of the following are you most concerned about going without? Check all that apply
Communication (alert warnings and messages, 911 and dispatch, first responders)
Maintaining Health (access to medical care, public health system, medication)
Independence (access to assistive devices, durable medical equipment, such as wheelchairs, walkers, scooters, and/or service animals)
Support Services, Safety and Self-determination (access to people who may support you, law enforcement, fire services, search and rescue, community safety)
Transportation (public transportation, rideshare service, support person that provides transportation for me)
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?
Yes
No
I Do Not Know
21.
The format for the listening session is still being decided. What is your preference?
In-person, comfortable meeting with up to 15 people
Virtual, able to join using my computer or laptop
No preference
22.
Do you have a preference on the time of day to participate in a 2-hour discussion?
Morning (after 10 am)
Afternoon
Early evening
No preference
23.
Do you have any access needs or accommodations?
24.
Please type your name
25.
Please provide your email.
26.
Please provide your phone number.
27.
To enter the raffle, please enter your name.
28.
Please provide either your email or telephone number so we may contact you if your name is drawn in the raffle.
