Family Name: ________________________
YES - NO 1. Has your family rehearsed fire escape routes from
your home?
YES - NO 2. Does each member of your family have a bag with sturdy shoes, flashlight, heavy-duty gloves, and a whistle attached to their bed frame?
YES - NO 3. Does your family know what to do before, during, and after an earthquake or other
emergency situation?
emergency situation?
YES - NO 4. Do you have all heavy and hanging objects (especially over beds) secured in a way that
will prevent them from falling during an earthquake?
will prevent them from falling during an earthquake?
YES - NO 5. Do you have access to a battery-operated light or an operational flashlight in
every room? (use of candles is not recommended in case of leaking gas)
every room? (use of candles is not recommended in case of leaking gas)
YES - NO 6. If a water line was ruptured during an earthquake, do you know how to shut off the
main water line to your house?
main water line to your house?
YES - NO 7. Can this water valve be turned off by hand without the use of a tool? or
Do you have a tool attached to the valve if one is needed?
YES - NO 8. Do you know where the main gas shut-off valve to your house is located?
YES - NO 9. If you smell gas, do you know how and would you be able to shut off this valve?
YES - NO 10. Gas valves usually cannot be turned off by hand. Is there a tool attached to your valve?
YES - NO 11. Would you be able to safely restart your furnace when gas is safely available?
YES - NO 12. Do you have working smoke alarms in the proper places to warn you of fire?
YES - NO 13. In case of a minor fire, do you have a fire extinguisher that you know how to use?
YES - NO 14. Do you have copies of important information and documents in a fire-safe location
ready for evacuation?
ready for evacuation?
YES - NO 15. Do you have duplicate keys and copies of important insurance and other papers
stored outside your home?
stored outside your home?
YES - NO 16. Do you have a functional emergency radio to receive emergency information?
YES - NO 17. If your family had to evacuate your home, have you identified a local meeting place?
IF AN EMERGENCY LASTED FOR THREE DAYS (72 HOURS) BEFORE HELP WAS AVAILABLE TO YOUR FAMILY••••••
YES - NO 18. Would you have sufficient food?
YES - NO 19. Would you have the means to cook food without gas and electricity?
YES - NO 20. Would you have sufficient water for drinking, cooking and sanitary needs?
YES - NO 21. Do you have access to a 72 hour evacuation kit?
YES - NO 22. Would you be able to carry or transport these kits?
YES - NO 23. Have you established an out-of-state family contact?
YES - NO 24. Do you have a first aid kit in your home and in each car?
YES - NO 25. Do you have work gloves and some tools for minor rescue and clean up?
YES - NO 26. Do you have cash - in small bills - on hand? (Banks/ATM's close during
emergencies)
YES - NO 27. Without electricity and gas do you have a way to heat at least part of your house?
YES - NO 28. If you need medications, do you have a month's supply on hand?
YES - NO 29. Do you have a plan for toilet facilities if there is an extended water shortage?
YES - NO 30. Do you have supplies to filter or treat water from a questionable source"
31. Do you have a supply of food, clothing, and fuel where appropriate:
YES - NO For 3 months?
YES - NO For a year?
These are all questions that need correct answers if you are to be safe in an emergency.
If you answered “No" to any of them, it's time to start taking steps toward getting those items
done!