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Special Needs Survey

  1. Personal information for individual with need

  2. Is primary phone TTY/TTD?

  3. Weight over 300 pounds

  4. Personal Information for Emergency Contact

  5. Evacuation Information

  6. Individual is/has:

  7. Does not:

  8. Has difficulty walking and requires:

  9. Requires medical equipment that is not easily transportable:

  10. Duration of Need:

    Are all of the conditions resulting in the need for evacuation assistance temporary? (Example: Bedridden due to pregnancy difficulties but expected to be fully recovered after the baby is deliverd.)

  11. Condition(s) are temporary

  12. Additional Information

  13. Does the person in need have a service animal?

    (i.e: seeing eye dog)

  14. Does the person have a 24 hr. caregiver?

  15. Does the person have pets?

  16. Does the person require evacuation assistance 24/7?

  17. Does the person have medications that must be taken with them if evacuated?

  18. Is this person a seasonal resident?

  19. Leave This Blank:

  20. This field is not part of the form submission.