Free Climate Change Vulnerability Assessment Form

Please complete the following questions to help assess your vulnerability to climate change impacts.
Personal Information
Name
Age
Phone number
Address
What climate hazards have you experienced in your area in the past 5 years?
(Check all that apply)
Extreme heatwaves
Flooding
Drought
Wildfires
How often do these climate events occur in your area?
Rarely
Occasionally
Frequently
Do you have any medical conditions that may be worsened by climate events?
If yes, please specify
Are you reliant on resources or utilities (e.g., electricity, water) that are often disrupted by extreme weather events?
What types of emergency resources do you currently have access to?
Generators
First aid kits
Stored water
How do you currently prepare for a climate-related emergency?
Creating a plan
Storing supplies
Staying informed
What additional resources or support would help you feel more prepared for a climate emergency?
Community programs
Training
Financial assistance

Thank you for completing this assessment.
Your responses will help us better understand climate change vulnerabilities and work towards effective solutions.
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