COMMUNITY EMERGENCY PREPAREDNESS, DISASTER RESPONSE AND PUBLIC SAFETY SURVEY ABOUT THE CITIZEN CORPS In his 2002 State of the Union message, President George W. Bush announced the creation of the USA Freedom Corps, an umbrella organization that includes the Peace Corps, AmeriCorps, Senior Corps and the newly created Citizen Corps. He did so in an effort to expand opportunities for all Americans to help protect our homeland, support our communities and extend American compassion around the world. The mission of the Citizen Corps is to harness the power of every individual through education, training, and volunteer service to make our communities safer, stronger, and better prepared to respond to the threats of terrorism, crime, public health issues, and disasters of all kinds. In keeping with its long tradition of volunteer activism, Fresno is proud to have been among the first communities in the nation to establish a Citizen Corps. The Fresno Citizen Corps has been created to add volunteer capacity to the region's public safety and emergency response organizations as well as to engage more citizens in the welfare of the community. The Fresno Citizen Corps is serving as a link between the region's many volunteer, faith-based, health-care, business, military, public safety and emergency response organizations, and in the process it is helping to build a more strongly bonded community. Citizen Corps programs include Volunteers in Policing, Police Activities League, Neighborhood Watch, Community Emergency Response Teams (CERT) and the Medical Reserve Corps, and others. For additional information, visit the Fresno Citizen Corps website at www.FresnoCitizenCorps.org. PURPOSE OF THE FAITH COMMITTEE The purpose of the Faith Committee is to identify resources and to build relationships among key stakeholders in our community. This will help the Fresno-area faith community be better prepared to respond to on-going volunteer opportunities that will lead to a safer and healthier community. And, in the event of a major disaster, the faith community will be able to do what it does so effectively—respond to the needs of individuals and families in times of crisis. PURPOSE OF THE HOUSE OF WORSHIP SURVEY The purpose of this House of Worship survey is to help the Citizen Corps identify both physical and human resources—facilities and potential volunteers within the faith community that may be available in the event of a major disaster, and to serve the ongoing needs of our public safety agencies. INSTRUCTIONS This survey asks for information in three categories—general information about your house of worship; physical resources such as facilities and/or vehicles that might be used in a disaster; and human/volunteer resources for disaster preparation and response, as well as meeting ongoing public safety needs. This survey should only take a few minutes to complete, and your time is greatly appreciated. Feel free to provide additional information or to clarify or amplify your responses on a separate sheet of paper. Thank you for your time HOUSE OF WORSHIP INFORMATION House of Worship: ______________________________________________________________ Person completing this survey:____________________________________________________ Title:_________________________________________________________________________ Address: _____________________________________________________________________ Major cross streets: _____________________________________________________________ City: _______________________________ Zipcode: __________________________________ Phone:________________________________ Fax: __________________________________ E-mail: _____________________________ Website: __________________________________ Name and title of the Pastor, Rabbi or spiritual leader of the House of Worship: ______________________________________________________________________________ Leader’s phone:_________________________ E-mail:__________________________________ Number of adults you serve:___________________________________Children:_____________ Do you offer translation or other support services for non-English speakers? Please describe: ______________________________________________________________________________ Do you offer services to individuals with special needs (listening devices or sign language interpretation, wheelchair assistance, sighted guide for the blind, etc.) If so, please describe: ______________________________________________________________________________ PHYSICAL RESOURCES – DISASTER RESPONSE Please respond regarding your House of Worship’s physical resources that may be used in a disaster; such as buildings, vehicles, equipment, etc. Do you have a gym, large fellowship hall or classroom that would be available to house people from the community in the event of a disaster? Yes No If yes, estimate the number of people that you could house? __________ Are your facilities (halls, restroom, etc.) wheelchair accessible? Yes No Does your facility have a commercial-type kitchen? Yes No If yes, estimated number of people you could feed in a crisis? __________ Do you have a food pantry for food distribution to those in need? Yes No Do you have a clothes closet for clothing distribution to those in need? Yes No Do you have van(s) and/or bus(es) that could be used during a crisis? Yes No If yes, please describe__________________________________________________________ Are your vehicles wheelchair accessible? Yes No Do you have licensed drivers for these vehicles? Yes No Do you have childcare facilities on site? Yes No Please describe any other equipment or physical resources that you may be able to provide in the event of a significant local emergency (generators, ham radios, warehouse, etc.): ____________________________________________________________________________ ____________________________________________________________________________ Person to contact to access disaster resources:______________________________________ Phone: _______________________________ Cell:__________________________________ VOLUNTEER RESOURCES Would your House of Worship be willing/able to mobilize volunteers in an emergency to assist at your facility or in the community? Yes No Estimated number of volunteers that you could mobilize: ______________________________ Would your House of Worship be willing/able to provide volunteers to assist Police or Fire agencies with ongoing public safety programs? Yes No Please complete the next section if you have information about the occupations and/or skills of your members who may be called upon to serve the community. ________ We do not maintain information regarding the occupation or skills of our members. If you have the following individuals within your House of Worship, estimate the number below. ______ Medical Doctors ______ Nurses or LVN’s ______ Paramedics/EMTs ______ Psychologists and crisis counselors ______ Individuals trained in CPR/First Aid ______ Retired* public safety personnel (Police Officers, Sheriffs Deputies, fire fighters, military) * Those who would not already be part of a disaster response operation and who could provide volunteer surge capacity. ______ Other (amateur radio operators, translators, etc.) Please describe _________________ (Use additional pages, if needed)