Preparedness Survey
Debt
(1) Are you debt-free?    Y     N
(If "yes", skip to section "Food Storage".)
(2) Please complete questions indicating what type of debt you have;
a) home mortgage      		Y        N
b) car                               	Y        N
c) credit card             	        	Y        N
d) recreational vehicle(s)  	Y        N
e) other                          	Y        N
(3) Approximately, what is the total monetary amount of debt you currently carry? ________
(4) Are you actively following a plan to become debt-free?  	Y        N
(5) Estimate how many years/months before you become debt-free._____

Food Storage
(6) Do you have a functioning home food storage program?            Y        N
(7) How many gallons of water do you have stored (not including water heater, toilet tanks)? _______
(8) How many pounds of grain and/or legumes do you have stored (rice, wheat, etc)? ______
(9) Are you using your storage items on at least a weekly basis?     Y        N
(10) How many rotating food supplies?
a) cans (soup, vegetables, etc.)________
b) powdered milk _____________
c) other (list item & amount) _____________
d) other (list item & amount) _____________
e) other (list item & amount) _____________
f) other (list item & amount) _____________
g) other (list item & amount) _____________
(1 l)Estimate how many months your family could survive on your overall food storage: __________

Fuel Storage & Use
Please answer the following as if electricity/natural gas service is disrupted:
(12) Do you have an alternative heating source (wood burning stove, propane, etc.)           Y       N
(13) Estimate how many days of fuel for such heating you have stored: _____
(14) Estimate how many hours lighting you have stored (candles, lanterns, generator, etc.): _______
(15) Do you own an alternate cooking device?  	Y       N
(16) Do you own dutch oven/outdoor cookware? 	Y        N

Medical Supplies
(17) Do you have a family first aid kit?         Y        N

Personal Hygiene
(18) Do you have a chemical toilet?   Y        N
(19) How many pounds of soap/detergent do you have stored? ________
(20) How many bars of hand/bath soap do you have stored? ___________
(21) How many boxes of Kleenex tissues do you have stored? _________
(22) How many rolls of toilet paper do you have stored? __________
(23) How many rolls of paper towels do you have stored? _________

Alternative Dwelling
(25 ) Do you have an alternative dwelling if house became unlivable? (tent, camper, trailer, etc.)?	       Y	    N
(26) Do you have a 72-hour kit for each family member? 	Y	N