PLEASE COMPLETE THE SURVEY BELOW. Your answers to the following questions will provide the City of Rolling Hills with important data and a list of resources in the event of a City emergency. The information collected will be provided to City authorized emergency response workers and Block Captains in preparation for and for implementation of a disaster response. With the information, officials will have knowledge of resident’s skills, equipment, and special circumstances for an effective emergency response.
Please provide the information below for all residents living at your address.
After completing the survey and clicking on "submit" below, you will be connected to the City of Rolling Hills Emergency Notification System for the purpose of inputting emergency contact information. The emergency contact information will be used to contact you in a public safety emergency.
If you already completed this survey and would like to update your contact information for the Rolling Hills emergency notification system, please click on the following link:
This information is being completed by:
Commute time to this City from work:
Hours normally at work:
Hours normally at home:
1. Are there small children at your home? (If no, skip to question #4)
2. Do the children have instructions on what to do following a disaster situation?
3. Is your regular child care prepared to care for the children under emergency circumstances (medical release papers, etc.)?
Child Care Provider:
4. Are any individuals at your home disabled (hearing, sight problems, etc.)? Does anyone require regular assistance due to specific medical conditions?
5. Will a disable person(s) have the ability to call or signal for assistance (whistle, etc.)?
6. Is a member of your household non-English speaking?
7. How many pets do you have on your property?
Describe which animals and how many you have:
8. Is there a member of the household who is in Active Military Reserve?
If yes, please describe state branch and field:
9. Would rescuers have a difficult time entering or exiting your property?
10. Do you, or any persons in your household, have medical training (Doctor, Nurse, EMT, Dentist, etc.)?
11. Is anyone in your household trained in the following? Building Inspector, Electrician, General Contractor, Structural Engineer. What specific field?
12. What is the primary language spoken in your home?
Please provide primary language spoken if not provided above:
13. Is anyone trained in the following:
Please indicate the number of people trained in each field marked above:
Resident Equipment and Resources Available
14. Is there special equipment in your household that could be used for rescue (4 Wheel Drive, Skip Loader, Hoists, Dump Truck, Horse Trailers, Vehicles with Trailer Hitches, ATV, Wheel Chair, Oxygen Tank, etc.)?
15. Does your property have a pool or spa?
15a. Do you have an auxiliary pump to deploy pool water for extinguishing a fire?
16. Does your household have a HAM radio?
Or a HAM radio base station?
If yes, would you volunteer your services to operate in an emergency?
17. Do you or members of your household have equipment or resources that would be of assistance in a disaster not mentioned above? If so, please explain:
18. Could you assist in transporting or handling horses in an emergency? If yes, please include the number of horses you could transport.
19. Would you be able to provide temporary shelter for horses? If yes, how many horses, besides your own, could your property accommodate?
20. Do you have food and drinking water available for your pets for at least 3 days?
21. Would you be able to provide temporary feeding and water for horses in an emergency? If yes, how many horses, besides your own, could you feed and provide water for (also include days)?
22. Supplies stored:
Personal Preparedness and Checklist
23. Do you have food, water, personal supplies, and small denominations of money for 7 days?
24. Do you and your responsible family members know the location of your main gas and water shut-off valves?
Do you have the proper tools available to shut off these valves?
25. Do you have adequate camping gear (lights, heating supplies, generator, sleeping bags, tents, appropriate fuel or separate power supply)?
26. Do you and your family members have an out-of-state contact for communication with members of your family?
27. Have you identified the most critical items to take from your house if ordered by public safety personnel with very little notice to evacuate?
Reminder: Don't forget to include your prescribed medications in your Personal Preparedness Kit!
28. Do you have an interest in volunteering to assist in emergency relieve/clean up efforts following a disaster in the City?
29. Are you willing or able to contact your neighbors on your street in an emergency situation?
* indicates required fields.