City of Rancho Palos Verdes Electronic Submittal

4. RANCHO PALOS VERDES COMMUNITY ACTION NETWORK 
   (RPV CAN) SURVEY

   As part of the City of Rancho Palos Verdes’ emergency preparedness planning efforts, the City seeks to collect information from its residents in advance of an emergency. Rancho Palos Verdes residents are encouraged to complete this survey and join the RPV Community Action Network (RPV CAN). RPV CAN is a framework to connect neighborhoods with emergency information, encourage neighborhood preparedness, and establish a communication chain of command between residents and the City in the event of a major emergency. 

   Information will be kept confidential and maintained as a database by the City. Please note that the City cannot guarantee that participants in the RPV CAN program will be contacted through the network. First responders use a variety of methods to communicate and implement emergency protocols; always follow their directions. Please direct questions to PublicSafety@rpvca.gov.

8. CONTACT INFORMATION:

9. First and Last Name
11. Home Address (must be resident of Rancho Palos Verdes)
13. Mailing Address (if different)
15. Phone Number
16. Email

20. EMERGENCY CONTACT INFORMATION:

21. First and Last Name
23. Address
25. Phone Number
26. Email

30. PERSONAL PREFERENCES

    This section will assist the City's emergency planning efforts.

32. Living Situation (select one)

    1. Live alone
    2. Live with at least one other person
    3. Other
33. Do you have pets?

    1. Yes
    2. No
34. Primary Language
36. Preferred method of communication (select all that apply)

    1. Phone call
    2. Text
    3. Email
    4. In-person
    5. American Sign Language (ASL)
37. Primary method of transportation (select all that apply)

    1. Personal vehicle
    2. Friend, relative, or caregiver vehicle
    3. Public transportation
    4. Rideshare service
    5. Not Applicable (e.g. homebound)
    6. Other
38. Do you need assistance to get out of your house?

    1. Yes
    2. No
40. Do you use any mobility assistance devices (e.g., cane, wheelchair, etc.)?

    1. Yes
    2. No
41. If you are medically dependent on electricity, have you signed up for Southern California Edison’s Medical Baseline Allowance Program?

    1. Yes
    2. No
    3. Not Applicable
42. Do you have a three-day emergency kit prepared?

    1. Yes
    2. No

    (See https://www.ready.gov/kit for how to build a kit) 

44. If you are completing this form on someone’s behalf, please indicate your name, relationship to the individual, and your best contact information:
45. Special Requests or Additional Information:

49. VOLUNTEER TO BE A NEIGHBORHOOD REPRESENTATIVE

    RPV CAN relies on neighborhood volunteers, known as Neighborhood Representatives, to help communicate emergency preparedness information from the City to their neighbors. All training will be provided and no prior experience is necessary. Additional information on RPV CAN and becoming a Neighborhood Representative is available at rpvca.gov/CAN. 

51. Would you like to volunteer to be a Neighborhood Representative?

    1. Yes
    2. No
53. If you selected yes, please provide a brief description of why you would like to be a Neighborhood Representative:
54. If yes, please describe your previous volunteer experience or other applicable experience:
58. Can the information you have provided in this survey be shared with your Neighborhood Representative? *

    1. Yes
    2. No
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field