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# Emergency Measures Questionnaire
The RM of Roland is collecting basic household information as a vital step in our community's emergency preparedness plan. Our goal is to ensure the safety and well-being of all residents in the event of an unforeseen situation, whether it's a severe weather event like a blizzard or flood, a major power outage, or any other emergency.
The information collected helps us respond quickly and effectively in an emergency situation.
1. Household Occupants- Names, Ages and if any assistance is required
Assistance Requirements- Please check any that apply to all occupants in your household:
Mobility Assistance (e.g. wheelchair, walker)
Communication barriers (e.g. hearing or visual impairment)
Childcare for infants/young children
Medical conditions requiring special attention/equipment (e.g. oxygen, dialysis)
Cognitive/Developmental assistance
Language barriers (please specify)
Other specific assistance requirements or important notes:
2. Phone Number(s)
3. Household Pets
4. Do you have livestock that needs to be looked after in the event of an emergency?
5. Resources available for the RM use during an emergency? Please check all that apply.
Snowmobile
ATV
Water Pump
Equipment
Water Tank
Generator
Other
If Other, please list:
6. Physical Address