Living Alone Checklist Form
Review your home-readiness and daily self-sufficiency essentials for living alone. Complete this checklist to ensure your comfort, safety, and preparedness.
Full Name
*
First Name
Last Name
Primary Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Emergency or Support Contact (Name & Phone)
*
Is your home equipped with working smoke detectors and locks on all doors and windows?
*
Yes
No
Not sure
Which essential supplies do you have at home?
*
Drinking water
Non-perishable food
First aid kit
Flashlight & batteries
Medication (if needed)
Other
Do you have a daily routine or checklist for home tasks (e.g., locking doors, turning off appliances, taking medication)?
*
Yes
No
How confident do you feel about your ability to handle emergencies alone?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
What is your preferred method for staying connected with friends or family?
Please Select
Phone calls
Text messages
Video calls
In-person visits
Other
Additional notes or comments
Submit Checklist
Should be Empty: