Buchanan Community Resilience

1. What is the full address for this household? *

Address 1	*
Address 2	*
Address 3	*
Postcode	*

2. Please provide details for everyone in normally living in your household? (Person 1) *

First Name	*
Last Name	*
Current Age	*
Occupation (even if now retired)	*
Mobile Phone Number	*
Email Address	*
Are you in any of the categories vulnerable to the Coronavirus (diabetic, over 65, asthma, other lung problems, other health challenges)	*
Do you have a current driving licence	*
Do you have access to a vehicle	*
Do you have any other relevant skills or training (e.g. medical training, 1st aid, catering, emergency services, military)	*
Are you willing and able to provide practical help in the community if needed (NB. You might not feel able to say yes, for lots of reasons. It is OK to say no)	*

3. Please provide details for everyone in normally living in your household? (Person 2)

First Name
Last Name
Current Age
Occupation (even if now retired)
Mobile Phone Number
Email Address
Is this person in any of the categories vulnerable to the Coronavirus (diabetic, over 65, asthma, other lung problems, other health challenges)
Does this person have a current driving licence
Does this person have access to a vehicle
Does this person have any other relevant skills or training (e.g. medical training, 1st aid, catering, emergency services, military)
Is this person willing and able to provide practical help in the community if needed (As above, it is OK to say no)

4. Please provide details for everyone in normally living in your household? (Person 3)

First Name
Last Name
Current Age
Occupation (even if now retired)
Mobile Phone Number
Email Address
Is this person in any of the categories vulnerable to the Coronavirus (diabetic, over 65, asthma, other lung problems, other health challenges)
Does this person have a current driving licence
Does this person have access to a vehicle
Does this person have any other relevant skills or training (e.g. medical training, 1st aid, catering, emergency services, military)
Is this person willing and able to provide practical help in the community if needed (As above, it is OK to say no)

5. Please provide details for everyone in normally living in your household? (Person 4)

First Name
Last Name
Current Age
Occupation (even if now retired)
Mobile Phone Number
Email Address
Is this person in any of the categories vulnerable to the Coronavirus (diabetic, over 65, asthma, other lung problems, other health challenges)
Does this person have a current driving licence
Does this person have access to a vehicle
Does this person have any other relevant skills or training (e.g. medical training, 1st aid, catering, emergency services, military)
Is this person willing and able to provide practical help in the community if needed (As above, it is OK to say no)

6. Please provide details for everyone in normally living in your household? (Person 5)

First Name
Last Name
Current Age
Occupation (even if now retired)
Mobile Phone Number
Email Address
Is this person in any of the categories vulnerable to the Coronavirus (diabetic, over 65, asthma, other lung problems, other health challenges)
Does this person have a current driving licence
Does this person have access to a vehicle
Does this person have any other relevant skills or training (e.g. medical training, 1st aid, catering, emergency services, military)
Is this person willing and able to provide practical help in the community if needed (As above, it is OK to say no)

7. Please provide details for everyone in normally living in your household? (Person 6)

First Name
Last Name
Current Age
Occupation (even if now retired)
Mobile Phone Number
Email Address
Is this person in any of the categories vulnerable to the Coronavirus (diabetic, over 65, asthma, other lung problems, other health challenges)
Does this person have a current driving licence
Does this person have access to a vehicle
Does this person have any other relevant skills or training (e.g. medical training, 1st aid, catering, emergency services, military)
Is this person willing and able to provide practical help in the community if needed (As above, it is OK to say no)

8. If you can think of any other relevant information, please add it here:

Powered by SmartSurvey

Create your own free online survey.