Dublin's Emergency Management Department needs your help. Please print and take the survey below and send it to:
The Office of Emergency Management
c/o Dublin Fire Department
P.O. Box 370
Dublin, NH 03444
Your cooperation is appreciated and your input will help us be ready for the next emergency event (remember the Ice Storm?).
OFFICE OF EMERGENCY MANAGEMENT
TOWN OF DUBLIN, NH
COMMUNITY VOLUNTEER SURVEY
DECEMBER, 2009
I am interested in assisting in an emergency and/or interested in learning more. Yes _____ No _____
Name: ________________________________________________________________ Age: _________
Mailing Address: ______________________________________________________________________
Physical Address: ______________________________________________________________________
Home phone: ______________________________ Cell phone: _______________________________
Email address: ________________________________________________________________________
Do you work in town or out-of-town? May we contact you at work? Yes _____ No _____
If so, please list your work number: _______________________________________________________
How do you receive information regarding local/national news, health alerts, community emergencies, etc.?
Computer ____ TV ____ Telephone ____ Radio ____ Newspaper ____
Other: ____ Please explain: ______________________________________________________________
Neighbor-helping-neighbor program: The Emergency Management Office would like to expand on its neighborhood program, whereby each road in town had a primary and secondary contact person who would be willing to check on their neighbors or be responsible for contacting each person in the event of an emergency. Would you consider being one of these contact people? Yes _____ No _____
How can we help you?
In the event of an emergency, do you have any special requirements where you may need assistance from us during an emergency?
If so, what are your special needs? Wheelchair _____ Oxygen needs _____ Hearing/sight impaired _____
Language barrier _____ Other: _____________________________________________________________
How can you help us?
DO YOU HAVE EXPERTISE OR TRAINING IN ANY OF THE FOLLOWING AREAS? CHECK MARK /CIRCLE WHERE APPROPRIATE.
First Aid/CPR ____ EMT/Paramedic/Nurse ____ Physician (what kind?) _____
Social Services (explain) _______________________ Firefighting ____ Veterinarian _____
Search/Rescue _____ Law Enforcement ____ Military _____ Survival Training _____
Camping _____ Runner/Jogger _____ Mechanic _____ Ham/CB Radio Operator _____
Multi-lingual (what languages?) _________________________________________________________
Emergency planning/management _____ Shelter Management _____ Elderly Care _____
Food Mgmnt/Preparation _____ Recreational Leader (ie, boy scouts, brownies, etc.) _____
School Teacher _____ Construction (electrical/plumbing/carpentry) ______ Bus/Truck Driver _____
CDL license _____ Structural Engineer _____ Waste Disposal _____ Communications (explain) _____
Journalism _____ Chain Saw skills _____ Boiler/furnace repair _____
Other skills: _________________________________________________________________________
Operator of heavy equipment (front loader/dump truck/etc): please explain _____________________
Could you provide temporary shelter? _____ For how many? _____ Can you transport? _____
Do you have a generator for your heat/water/electricity? Yes _____ No _____
Animal handling: small _____ medium _____ large _____ Can you provide shelter? _____
Care for _____ Transport _____
In case of an emergency, could you provide:
Boat _____ livestock/horse trailer _____
Dump truck _____ portable generator _____
Front-end loader _____ air compressor _____ small _____ large _____
Back hoe _____ chain saw _____
Bulldozer _____ off-road vehicle _____
Tractor _____ snowmobile _____
Portable lighting _____ pick-up truck _____
Pumps _____ truck hitch _____
Thank you for helping us determine the important volunteer resources in our community!
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