Charlottesville Cert Member Questionnaire

CHARLOTTESVILLE CERT MEMBER QUESTIONNAIRE

Your name: Home address: Email addresses (es): Phone number(s): Today’s Date:

Have you completed all the CERT classes? (Yes/No) If no, then list classes missed:

On a scale of 0 to 5 with 0 being no experience and 5 being an expert, please answer the following: General computer experience (0 to 5): Microsoft Word experience (0 to 5): Microsoft Excel experience (0 to 5): Microsoft Access experience (0 to 5): Chain saw experience (0 to 5): Digital camera experience (0 to 5) Reading and following maps (0 to 5): Reading and following a USGS topographic maps (0 to 5): Using a magnetic compass (0 to 5): Using a GPS device (0 to 5): Hooking up a trailer to a truck and towing a trailer with electric brakes (0 to 5): Working with hand power tools in general (e.g. drills, sanders, saws, nail guns) (0 to 5): Cabinet making or framing (0 TO 5) Other skills and abilities not listed (0 to 5): Medical skill level (none, CERT, EMT, nurse, doctor Teaching skills: CPR instructor, first aid instructor, other

I can drive a vehicle with a manual stick shift? (Yes/No)

Lifting heavy objects (40-50 lbs) is a problem for me? (Yes/No/Sometimes)

I prefer office or field work? (Office/Field/Either)

Have you had CPR training? (Yes/No) If yes, date of training:

List other formal emergency responder type training that you have had beyond the CERT program:

I am willing to be deployed in situations that might require an overnight stay: (Yes/No/Maybe)

I am willing to be deployed outside our region but within Virginia that might require an overnight stay: (Yes/No/Maybe)

I am willing to be deployed outside Virginia that might require an overnight stay: (Yes/No/Maybe)

If CERT is activated for an incident I am willing to work an 8 hour shift: (Yes/No/Maybe)

How many minutes does it take you to get from your home to the 911 Center?

Closest main highway intersection to your home:

Route you would take from your home to the 911 Center:

I am interested in the following additional cert training classes:

Ride-alongs with police, fire or rescue units 911 Center sit-ins, to observe dispatchers Chain saw safety and operations Damage assessment Orienteering Rope handling and knot tying Traffic control Tabletop exercises Annual regional exercises CPR/AED Training Amateur radio training leading to a license Weather Spotter training through the National Weather Service Flagger training (can benefit you as CERT members when conducting traffic control) Pets in disaster Fire Wise specialist with the Dept. of Forestry on protecting your homes from forest fires Terrorism Suspicious activities awareness training (CATS Eyes)