SPECIAL NEEDS EVACUATION
REGISTRATION FORM
_________________
(DATE)
TYPE OF REPORT:
___Initial.
___Change.
NAME: ___________________________ _____________________ _________________
(LAST) (FIRST) (MIDDLE)
STREET (or 911) ADDRESS_________________________________________________________
MAILING ADDRESS:______________________________________ SSI:_________________________
CITY:___________________________________,
STATE:____________. ZIP:___________.
PHONE: (
) _______ . TDD:________. DOB:______________
SPEAKS ENGLISH: (Y)(N)(UNK)_______
LIVING SITUATION:_______(See Codes)
RURAL: (Y)(N)(UNK)_____ FRAIL: (Y)(N)(UNK)_____ PRIMARY HANDICAP:_____(See Codes). AGE:___________ SEX:____________ RACE:_______________
LIVES
ALONE: YES____. NO____. LIVES WITH CAREGIVER: YES____.NO____
REFERRING AGENCIES:_____________________________________________________
DIRECTIONS TO HOME:_________________________________________________________________
________________________________________________________________________________________
_________________________________________________________________________________________
(Use 'X' to mark the
following fields:)
{ } NO SPECIAL CHARACTERISTICS { } MEMORY IMPAIRED
{ } MOBILE HOME/TRAILER { }
MENTAL HEALTH IMPAIRED
{ } MED. DEPENDENCE ON ELECTRICITY { } ANXIETY/DEPRESSION
{ } OXYGEN DEPENDENT { }
SPEECH IMPAIRED
{ } RESPIRATOR DEPENDENT { }
{ } INSULIN DEPENDENT
{
} CARDIAC HISTORY
{ } DIALYSIS DEPENDENT
{ }
EMERGENCY ALERT EQUIP.
{ } LIFE-SUSTAINING MEDICATIONS
{ } NO TELEPHONE
{ } BEDRIDDEN
{ } INCONTINENCE
{ } WHEELCHAIR BOUND
{ } SPECIAL DIETARY NEEDS
{ } MOBILITY IMPAIRED
{ } NO ALTERNATE HOUSING
{ } SIGHT IMPAIRED
{ } NO EMERGENCY HEAT
{ } HEARING IMPAIRED
{ } OTHER
(describe in comments)
EMERGENCY CONTACT: LAST NAME: ________________________, FIRST:__________________.
PHONE1:_________________. RELATIONSHIP:___________________.
PHONE2:_________________. RELATIONSHIP:___________________
OUT-OF-STATE CONTACT: LAST NAME:_______________________,FIRST:__________________.
PHONE1:_________________. RELATIONSHIP:___________________.
PHONE2:________________. RELATIONSHIP:___________________
DOCTOR'S NAME:____________________________________PHONE:______________ .
PHARMACY NAME:___________________________________ PHONE:______________.
{ } ZONE NUMBER
PRIORITY CODE:_______.
{ } SPECIAL NEEDS REGISTERED (
{ } PREAUTHORIZED HOME ENTRY.
DISASTER PLAN: (Use 'X' to mark the disaster plan
field) PETS: (give number of
each)
1. { }
STAYING AT HOME { } CAT
2. { } TO
ANY SHELTER
{ } DOG
3. { } TO
SPECIAL NEEDS SHELTER
{ } GUIDE DOG
4. { } TO
OTHER (Family, Friend, Hotel, Hospital, Nursing Home, etc.).
OTHER CONTACT:___________________________.PHONE:_______________.
5. { } NEEDS
TRANSPORTATION FOR ITEM 2, 3, OR 4. If
so, indicate type transportation
needed: STANDARD VEH:____. AMBULANCE:____. LIFT GATE:___.
Patient is:
AMBULATORY____. WHEELCHAIR____. STRETCHER____.
6. { } WILL YOU BRING A
CAREGIVER TO THE SHELTER: YES____. NO:____.
COMMENTS:_________________________________________________________________.
Report prepared by:_______________________________________________________.
CODES
LIVING SITUATION
HANDICAP
WS - With Spouse
D - Developmental
WB - With Spouse and Children
E - Epilepsy
WC - With Child (ren) H
- Hearing
WP - With Parent (s)
M - Mental
WO - With Other Relative
S - Speech
WN - With Non-Relative
V - Vision
GP - Group Quarters
I, the undersigned, give
permission to release above information to the Emergency Management Office for
assistance with evacuation in case of a Natural Disaster/Emergency. I, also, give the
Bradford
County Sheriff's Office permission to enter my home in case of an emergency.
WITNESS:_______________________________