JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Coastal Community Resilience Project Questionnaire
Sign in to Google
to save your progress.
Learn more
* Indicates required question
How prepared do you feel your household is for the next major storm or power outage?
*
Very prepared
Somewhat prepared
Not prepared at all
During storms, flooding, or power outages, what are the biggest challenges your household faces?
*
Access to food and clean water
Medical or mobility support
Reliable information and communication
Safe shelter or cooling
Transportation
Other:
Required
Which resources would be most helpful to you in an emergency?
*
Emergency food and clean water kits
First aid and medical supplies
Flashlights, batteries, and backup power
Help with transportation or evacuation
Emergency plans or information in my language
Other:
Required
What medical or mobility needs do you have that may affect you during emergencies?
Your answer
What groups in the community do you feel need the most support during emergencies?
*
Seniors/elders
Families with young children
People with disabilities/chronic illness
Youth and students
Other:
Required
Would you or someone in your household be interested in participating in workshops to learn about emergency preparedness, clean water, or environmental health?
*
Yes
No
Maybe, depends on the timing
What is your age?
*
Under 18
18-64
65+
Which neighborhood do you live in?
*
Garden City
Hudson Hill
Frazier Homes
Woodville
Other:
How would you prefer to receive updates about community resources and emergency plans?
*
Email
Phone/Text Message
Social Media
Flyers/Community Bulletins
Word of Mouth
Other:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report