The Office of Emergency Services (OES) of the city of Richmond is taking steps to expand and reenergize the REACT/CERT emergency preparedness program. One part of this effort is updating our list of residents and people who work in Richmond who have taken REACT/CERT emergency preparedness classes. In order to plan for effective response to an emergency, we need to be able to contact you, to inform you of additional training opportunities and to integrate REACT/CERT graduates into a local REACT/CERT team.

This form is secure, and your answers will be seen only by OES staff and authorized REACT/CERT volunteers (e.g., team leadership in your neighborhood). Some of the questions apply only to REACT/CERT graduates, and other questions apply to people who started but did not complete the training.

If you have not taken REACT/CERT training, please do not complete this form. Instead answer the questions at www.ci.richmond.ca.us/REACTInquiry

www.ci.richmond.ca.us/REACTInquiry

* indicates required fields

Section 1 -- FOR ALL RESPONDENTS

Which of the following applies to you? Read the choices here and then check your answer below:

1. I have graduated from REACT or CERT training, either in Richmond or elsewhere, including the hands-on "drill" at the fire department or equivalent.

2. I began but haven't graduated from REACT or CERT training, either in Richmond or elsewhere.

Please check which of the answers applies to you regarding your REACT training:*

Graduated

Began - Haven't Graduated

Contact Information:

First Name*

Last Name*

Home Phone*

Work Phone

Cell Phone

Email Address*

Note: Your physical address is required for our mapping purposes.

Street Number*

Street Name*

City*

State*

ZIP*

Neighborhood of Richmond in which you live. Please choose from the drop down list at right: *

Not Sure Atchison Village Belding Woods Brickyard Cove Homeowners Association # 1 Brickyard Cove Homeowners Association # 2 Brickyard Landing Homeowners Association Carriage Hills North Homeowners Association Carriage Hills South Homeowners Association Civic Center Improvement Association Coronado Cortez/Stege Countryside Downtown Association of Richmond Eastshore El Sobrante Hills Fairmede Hilltop Greenbriar Green Ridge Heights Hasford Heights Hilltop/Bayview Hilltop Green Homeowners' Association Hilltop Village Homeowners' Association Iron Triangle Laurel Park Marina Bay May Valley North & East Panhandle Annex Parchester Village Park Plaza Parkview Point Richmond Pullman Quail Hill Richmond Annex Richmond Heights Richmore Village Santa Fe Shields-Reid SW Richmond Annex Not Applicable

If you work in Richmond, please answer the following 3 questions:

What is the name of your employer?

What is your work address?

What is the neighborhood in which you work?*

Not Sure Atchison Village Belding Woods Brickyard Cove Homeowners Association # 1 Brickyard Cove Homeowners Association # 2 Brickyard Landing Homeowners Association Carriage Hills North Homeowners Association Carriage Hills South Homeowners Association Civic Center Improvement Association Coronado Cortez/Stege Countryside Downtown Association of Richmond Eastshore El Sobrante Hills Fairmede Hilltop Greenbriar Green Ridge Heights Hasford Heights Hilltop/Bayview Hilltop Green Homeowners' Association Hilltop Village Homeowners' Association Iron Triangle Laurel Park Marina Bay May Valley North & East Panhandle Annex Parchester Village Park Plaza Parkview Point Richmond Pullman Quail Hill Richmond Annex Richmond Heights Richmore Village Santa Fe Shields-Reid SW Richmond Annex

Section 2--FOR REACT/CERT GRADUATES ONLY
--NON-GRADUATES, PLEASE SKIP THIS SECTION AND CONTINUE WITH SECTION 3

Your REACT/CERT training history and current involvement in a REACT/CERT team:

In what year did you complete your REACT/CERT training? (use your best estimate if you don't remember)*

Please choose a year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

When did you participate in your most recent hands-on drill? *

Please choose a year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

If you took your REACT/CERT class in Richmond, at what location did you take it?

If you took your REACT/CERT class somewhere other than Richmond, in what city or jurisdiction did you take it?

Are you currently a member of a REACT/CERT team?

Yes

No

If YES, what is the team's neighborhood?*

Not Sure Atchison Village Belding Woods Brickyard Cove Homeowners Association # 1 Brickyard Cove Homeowners Association # 2 Brickyard Landing Homeowners Association Carriage Hills North Homeowners Association Carriage Hills South Homeowners Association Civic Center Improvement Association Coronado Cortez/Stege Countryside Downtown Association of Richmond Eastshore Neighborhood Council El Sobrante Hills Fairmede Hilltop Greenbriar Green Ridge Heights Hasford Heights Hilltop/Bayview Hilltop Green Homeowners’ Association Hilltop Village Homeowners’ Association Iron Triangle Laurel Park Marina Bay May Valley North & East Panhandle Annex Parchester Village Park Plaza Parkview Point Richmond Pullman Quail Hill Richmond Annex Richmond Heights Richmore Village Santa Fe Shields-Reid SW Richmond Annex Not Applicable

Richmond does not have enough REACT/CERT teams up and running. Would you be willing to help organize teams in your neighborhood?

Yes Maybe

No

Whether you currently belong to a team or not, please indicate each of your preferred or actual team role(s). We hope to use this list to inform you of future training in specific areas.

Team Leader/Incident Command

Yes

No

Operations (General)

Yes

No

Fire Suppression

Yes

No

Search and Rescue

Yes

No

Medical

Yes

No

Logistics (Equipment and Supplies)

Yes

No

Planning (General)

Yes

No

Communication

Yes

No

Situation Status

Yes

No

Mapping

Yes

No

Administration-Record Keeping

Yes

No

GRADUATES, PLEASE SKIP TO SECTION 4

Section 3--FOR NON-GRADUATES WHO HAVE TAKEN SOME REACT/CERT TRAINING.
GRADUATES PLEASE SKIP THIS SECTION AND CONTINUE WITH SECTION 4.

Your REACT/CERT training history:

In what year did you take your REACT/CERT classes? (use your best estimate if you don't remember)*

Please choose a year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

If you took your REACT/CERT classes in Richmond, at what location did you take it?

If you took your REACT/CERT class somewhere other than Richmond, in what city or jurisdiction did you take it?

The topics of the meetings of current REACT/CERT classes are briefly summarized below.

Disaster Preparedness; REACT/CERT team organization

I've taken this

I haven't taken this

Minor Fire Suppression; hazardous materials at home; shutting off utilities

I've taken this

I haven't taken this

Disaster first aid; triage and assessment of the injured

I've taken this

I haven't taken this

Minor search and rescue; lifting and cribbing

I've taken this

I haven't taken this

CERTs and terrorism; organizing REACT/CERT teams in your neighborhood

I've taken this

I haven't taken this

Hands-on practice drill at the fire department training center or equivalent

I've taken this

I haven't taken this

NOW CONTINUE WITH SECTION 4

Section 4--FOR ALL RESPONDENTS

Your additional skills:

Law Enforcement-non-Richmond/reserve/retired

Yes

No

Firefighter-non-Richmond/reserve/retired

Yes

No

FEMA disaster experience

Yes

No

Chemical/hazmat

Yes

No

Medical doctor/ nurse

Yes

No

Other health/medical skills

Yes

No

Mental health skills

Yes

No

CPR

Yes

No

Took a first aid class

Yes

No

Search and rescue

Yes

No

Shelter

Yes

No

Work regarding disability needs

Yes

No

Ham radio

Yes

No

Ham radio-RACES/ARES

Yes

No

Electrical

Yes

No

Plumbing

Yes

No

Carpentry

Yes

No

Clergy

Yes

No

Childcare

Yes

No

Please list other relevant skills:

Section 5--FOR ALL RESPONDENTS

Please use the space below for additional comments:

Thank you for completing this form. Your answers will greatly assist the office of Emergency Services as it works to help Richmond prepare for an emergency.

The information that you have provided will allow us to send you information about future citywide and neighborhood REACT/CERT program activities. The messages will come either from the office of Emergency Services staff at richmondprepares@ci.richmond.ca.us or from authorized REACT/CERT volunteers at richmondprepares@yahoo.com.