Special Needs Assessment Survey
   

   

    

      
PERSONAL INFORMATION:
        
First Name  
        
Last Name: 
        
        
        

        Male     Female   
        Age:
        
        
Street#
               
        Apt:
             
        
        
Street Name 
        
        
City 
        
        
State 
        
        
Zip 
        
        
Phone Number 
        
        
        
LIVING SITUATION
        
        
Alone   
        Care Giver 
        
  W/Spouse   
        Other (List) 
      
      
      
      
IN CASE OF EMERGENCY, LIST A NEXT OF
        KIN/CAREGIVER TO NOTIFY:
        
        
Next of Kin Name         
        
        
Phone Number               
        
        
Neighbor/Friend              
        
        
Phone Neighbor/Friend    
        
IMPORTANT NAMES AND NUMBERS:
        
Primary Physician's Name              
        
        
Primary Physician Phone Number   
        
Hospital Preference                        
        
        
Ambulance Co
        Used                        
        
        
 Ambulance Phone Number              
        
 
        
 
    
    

      
 
      
      
 
    
   
   

    

      
TRANSPORTATION/SHELTER INFORMATION
        
Do you have transportation to be able to evacuate          
        YesNo 
        
               
        
        
        
Can you get yourself to a shelter                                    
        YesNo 
        
        
Do you have a plan for shelter in case of evacuation       
        Yes
        No 
        
        
Is your Companion/Caregiver/Spouse going with you  
        Yes No 
		
		
Primary mode of transportation by car                          
         Yes No 
        
        
Primary mode of transportation by wheel-chair van       
        Yes No 

		
Primary mode of transportation by ambulance              
        Yes No 
		
        
Person completing Database Survey                    
        
        
Person completing Survey Phone Number           
        
        
        
Person completing Survey E-mail                         
        (REQUIRED)             

        
        
        
Organization                                                      
                     
 
Person completing E-mail                                  
        
        
        
(REQUIRED)
		
        
        
Date Survey completed                                      
        
        
(REQUIRED)
        
 
        
         
 
        
 
        
 
        
 
        
 
        
 
    
   
      
        

          

            

              

                

                  
 
                  Clients must be informed that the information obtained
                  for this Survey is for planning purposes only, it does
                  not imply or guarantee any response by any emergency response
                  agency. Information obtained is subject to privacy under the Texas
                  Government Code 418.175.
              
              
Texas
              Government Code 418.175. Certain
              Information Confidential
              
(a) Information that
              relates to physically or mentally disabled individuals or other
              medically fragile individuals and that is maintained for purposes
              of emergency management or disaster planning is confidential and
              excepted from required disclosure under Chapter 552.(b) This
              section applies to information in the possession of any person,
              including:(1) the state, an agency of the state, a political
              subdivision, or an agency of a political subdivision; or(2) an
              electric, telecommunications, gas, or water utility. Added by Acts
              1999, 76th Leg., ch. 778,  1, eff. June 18, 1999.
          
        
        

         

          

           

          

           
            

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Modified: June 26,2005 
Copyright  2002 CompanyLongName