NEIGHBORHOOD RESOURCE SURVEY Date_____________
| Section #__________ | Section Leader ________________________________________________________________ |
| Address __________________________________________________________________________________________________ |
| Household name __________________________________________________________________________________________ |
| Adults' names ____________________________________________________________________________________________ |
| Children, names and ages __________________________________________________________________________________ |
| __________________________________________________________________________________________________________ |
| Phone numbers - Home _______________________________ Work ______________________________________________ |
| Cell _____________________________________________________________________________________ |
| Out-of-state contact and phone ______________________________________________________________________________ |
| Equipment | Skills |
| _____construction equipment | _____nurse |
| _____generator | _____doctor |
| _____boat | _____dentist |
| _____pick-up truck | _____lawyer |
| _____trailer | _____psychologist |
| _____tow truck | _____school counselor |
| _____swimming pool | _____radio operator |
| _____CB radio | _____heavy equipment operator |
| _____ham radio | _____licensed truck or bus driver |
| _____chain saw | _____trained EMT |
| _____tent, size | _____CPR trained |
| _____firefighter | |
| _____policeman | |
| _____plumber | |
| _____electrician | |
| _____locksmith | |
| _____carpenter | |
| _____roofer | |
| _____arborist |
Special Needs:
Health:
Language:
Other: