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2. 
4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number
14. Fax Number
16. Organization Name(if applicable):
18. 1. Does your organization currently have an Emergency Operation Plan?

    1. Yes
    2. Yes, but need additional help
    3. No
    4. Don't Know
19. 1a. If no, would your organization be interested in putting one together?

    1. Yes
    2. No
20. 2. Would your organization like to schedule a presentation for 72 hour Emergency Preparedness?

    1. Yes
    2. No
22. 3. Does your organization currently have a Lock-In/Shelter In Place policy?

    1. Yes
    2. No
23. 3a. If no, would you like someone to contact you to help prepare your plan?

    1. Yes
    2. No
24. 4. Has your organization participated in Run/Hide/Fight training?

    1. Yes
    2. No
25. 4a. If no, would you like someone to contact you to help prepare your plan?

    1. Yes
    2. No
27. 5. Has your organization participated in American Red Cross CPR/First Aid Training?

    1. Yes
    2. No
28. 5a. If no, would you like someone to contact you to help prepare your plan?

    1. Yes
    2. No
29. 6. Has your organization participated in Stop the Bleed Training?

    1. Yes
    2. No
30. 6a. If no, would you like someone to contact you to help prepare your plan?

    1. Yes
    2. No
32. 7. Would your organization want information regarding the Roanoke Valley's - Community Emergency Response Team Training (CERT)?

    1. Yes
    2. No
33. 8. Have you recently participated in a security evaluation with the City of Roanoke's Community Involvement Officer??

    1. Yes
    2. No
34. 8a. If no, would you like someone from the Roanoke Police Department to contact you?

    1. Yes
    2. No
35. 9. Would you like someone from the Roanoke Fire Marshal's Office to contact you for help with your fire safety plan?

    1. Yes
    2. No
37. 10. Is your organization's building in the floodplain?

    1. Yes
    2. No
38. 10a. If yes, would you like to talk to a certified floodplain manager for mitigation suggestions?

    1. Yes
    2. No
39. 11. Would your organization benefit from a presentation or discussion to learn more about floodplains, reducing flood risk, and mitigation options?

    1. Yes
    2. No
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41. 1. Receive an email copy of this form.
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