Take 5 minutes right now to answer these questions and your customized master kit list can be created for you!
Click
here to download the questionaire.
Please download and complete the questionaire using (free) Acrobat Reader 9. Make sure you are using the current version of Acrobat Reader.
After completeting the questionaire, you may press the submit button at the bottom of the form and email it to us at kim@safebydesignco.com.
If you are unable to complete the form using Acrobat Reader 9, please print this page, answer the questions and fax it to 1-323-284-4755.
For questions, feel free to contact Award Winning FEMA Certified Emergency Specialist and Owner of SAFE BY DESIGN:
Kimberly Walls
T. 1-213-422-8356
F. 1-323-284-4755
E. kim@safebydesignco.com
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Quick Questionnaire (print)
Your Family Names (first and last):
Email:
Phone numbers:
- Tell us about the adults in your household:
- male or female
face mask size (xs, s, m, l)
glove size (s, m, l, xl) - male or female
face mask size (xs, s, m, l)
glove size (s, m, l, xl)
- male or female
face mask size (xs, s, m, l)
glove size (s, m, l, xl)
- male or female
face mask size (xs, s, m, l)
glove size (s, m, l, xl)
- Tell us about the children:
- male or female
age _____
current clothing size _______
potty trained Y or N
If not potty trained, diaper/pull-up size ______
attends school Y or N
- male or female
age _____
current clothing size _______
potty trained Y or N
If not potty trained, diaper/pull-up size ______
attends school Y or N
- male or female
age _____
current clothing size _______
potty trained Y or N
If not potty trained, diaper/pull-up size ______
attends school Y or N
- male or female
age _____
current clothing size _______
potty trained Y or N
If not potty trained, diaper/pull-up size ______
attends school Y or N
- male or female
age _____
current clothing size _______
potty trained Y or N
If not potty trained, diaper/pull-up size ______
attends school Y or N
- male or female
age _____
current clothing size _______
potty trained Y or N
If not potty trained, diaper/pull-up size ______
attends school Y or N
- How many of your family members go to an office/studio for work outside the home? 1, 2, 3, 4
- Do you have indoor pets? Y or N
- How many automobiles are regularly driven in your household? 1, 2, 3, 4
- Are the children driven around in the car(s)? Y or N
- What type of residence do you occupy? (check one) single family, apartment, duplex
- How many bedrooms in your home? 1, 2, 3, 4, 5, 6
- How many levels/stories is your home? 1, 2, 3, 4
- Are any of the bedroom/office doors closed for naps or at night? Y or N
- Do you have a50 gallon or larger water heater that is easily accessible from an outside wall/door that stores water (smallest size found in most homes is 50 gallons)? Y or N
- If NO water heater accessible, do you have room to store a discretely placed 30-gallon water drum outside your interior living space? Y or N
- Do you already have a compact/light-weight tent big enough for your family? Y or N
- For your toiletries kit, would you prefer to fill bottles with
your own shampoo, lotion, etc.
Or would you like us to select pre-filled containers from name-brand suppliers such as Pantene and Lubriderm. (check one) My own or Pre-filled.
- For adult pain medication, the anti-inflammatory Ibuprophen (Motrin/Advil), is typically included. As a secondary adult pain medication, do you prefer (check one) Acetaminophen (Tylenol), Naproxen (Aleeve), or Aspirin (Bayer)?
- Do you have a propane/butane camping stove? Y or N
- Does anyone in your family have severe allergies? Y or N
- Does anyone in your family take prescription medication? Y or N
- Does anyone in your family use a wheelchair? Y or N
- Does anyone in your family use prescription eyeglasses? Y or N
- Does anyone in your family use magnifying eyeglasses? Y or N
- Does anyone in your family have diabetes? Y or N