CVERA Survey

This survey is from Capay Valley community volunteers who have joined together to support our first responders and the community in case of fire, flood, heat or power-outage emergencies. Our organization is called CVERA, the Capay Valley Emergency Response Auxiliary and is a sponsored organization of the Capay Valley Volunteer Fire Department.

The purpose of this survey is to gather information about people in the community who might need help in an evacuation or assistance in the case of a loss of electrical power or during a heat event.

None of the information gathered by this survey will be made accessible to the general public. CVERA leadership will have access to it. In case of an emergency, some of the information could be shared with Yolo County Emergency Service agencies.

You are welcome to send any questions you may have to CapayValleyERA@gmail.com.

Thank you for filling out our survey and helping to make our community safer.

CVERA

Contact Information

_{(Please fill out this entire section)}

Your Name

Mailing Address

Check if your home address is the same as your mailing address

Home Address

Home Phone (###-###-####)

Cell Phone (###-###-####)

Evacuation Assistance

1. In the case of an evacuation, would you or anyone in your household need assistance (for example due to reduced mobility or lack of transport)?

Yes (see additional questions below)

No (go to question 2)

If you answered yes to question 1:

Please provide the name, age and phone number (if different than yours) of the person or people in your household who might need assistance during an evacuation: _{Note: CVERA volunteers might contact your household during an evacuation to ascertain that the individual(s) have been safely evacuated and if they have not, CVERA would work to provide assistance. (Remember, there is a chance that you might not be around to help this individual in an emergency.)}

Please describe any potential issues that emergency personnel might encounter in accessing your home (for example: roads that are sometimes impassable, animals, locked gates).

2. Do you have neighbors or friends in the Capay Valley community who you believe might need assistance to evacuate safely (for example due to reduced mobility or lack of transport)?

Yes (see additional question below)

No (go to next section)

If you answered yes to question 2:

Please provide any contact information that you have for the person(s) who you are concerned about (ie: name, physical address, phone number, mobile number).

Power Outages

1. Do you or anyone in your family rely on medical equipment that needs electrical power?

Yes (see additional question below)

No (go to question 2)

If you answered yes to question 1:

Please provide the name and age of the person or people in your household who would need generator power during a power outage or evacuation:

2. Please share contact information for any neighbors or friends in the Capay Valley community who you believe rely on medical equipment that needs electrical power:

Please include their name, physical address, home and/or mobile phone number

3. Do you or anyone in your family have medical issues that make them vulnerable during a heat wave?

Yes (see additional question below)

If you answered yes to question 3:

Please provide the name of the person or people in your household who might need a space to cool down during a heat wave (especially if the heat wave occurs in combination with a power outage):

Miscellaneous

1. Do you have any heavy equipment that you would be willing to share or operate during a local emergency, such as to protect structures from fire, or help evacuate people or livestock?

Yes (see additional question below)

No (go to question 2)

If you answered yes to question 1:

Please describe the equipment that you have:

2. Are you a ham radio operator?

Yes

3. Do you have any first aid, medical or emergency certifications?

Yes (see additional question below)

If you answered yes to question 3:

Please describe the type of training and/or certificates:

Contact Information

Evacuation Assistance

Power Outages

Miscellaneous

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