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Park County Emergency Evacuation Assistance Survey Please send completed survey to: Park County OEM, PO Box 1373, Fairplay CO 80440 This survey is for informational purposes only. Park County does not assume responsibility for providing transportation during evacuation situations. If you have special evacuation needs, please make prior arrangements to ensure your safety during a disaster or large-scale emergency. The purpose of this form is to determine an approximate number of citizens requiring evacuation assistance and to determine which types of assistance are most commonly needed. This survey will greatly assist the Local Emergency Planning Commission with further evacuation planning. Thank you in advance for your participation. Date: Resident Information: Only the person with special evacuation needs should fill out this form. Please print clearly. Name: Gender: M or F Last First MI (Circle One) Home Address: Apt. Bldg. City: Zip Code: Mailing Address (if different): Telephone: Hearing Impaired TTD # Age: Language Spoken: Veteran: Yes No Residence Type: Year-Round Part-time Resident Single Family Home Subdivision Name: Mobile Home / Trailer Park Name: Apartment / Condo Complex Name: Floor: Transportation Information: Would you need transportation in the case of an emergency evacuation? Yes No If yes, please check one of the following modes of transportation that would be needed: Car / Bus Wheelchair Van Ambulance Equipment your life depends on that must be transported with you: Does this equipment require electricity? Pet / Service Animal Information: None Cat Dog Other (please list # of each) Have you made arrangements to shelter your pet in an emergency? Yes No Do you have a pet carrier for each animal? ---PAGE BREAK--- Emergency Contacts: (Local) Name: Phone: (Non-Local) Name: Phone: Medical / Nursing Information I take care of myself at home Citizen is: Hard of hearing Quadriplegic I utilize part time nursing help at home. Blind Paraplegic I am unable to care for myself at home On a Ventilator Other Home Health Agency providing home care: Phone Do you have a caregiver that would be with you during an evacuation? Yes No What type of assistance do you require on a daily basis? (Check all that apply) Personal care (dressing/toileting) Mobility (walking/transferring) Taking Meds Guidance (visual impairment) Airway Suctioning Feeding Communicating (deaf/nonverbal) Oxygen (Intermittent/Continuous Dialysis Skilled medical/mental healthcare Other: Do you use medical equipment requiring electricity? Yes No Intermittent or Continuous? Oxygen Company: Phone Specific equipment requiring electricity: IMPORTANT NOTICE AND STATEMENT OF UNDERSTANDING The information contained herein is true and correct to the best of my knowledge. I have read and understand the information on this form and understand that this survey is voluntary. I understand that: I am responsible to PROVIDE FOR MY OWN BASIC AND SPECIAL NEEDS. LIMITED volunteer assistance may be available to assist me and/or my caregiver in the event that a shelter is opened. I will need to make alternative arrangements in the event that I am unable to return to my home after the incident. I will be responsible for any charges and costs associated with a hospital or other medical facility including care and medical transportation, if they should become needed. TRANSPORTATION: I may be ordered or recommended to evacuate my residence. All attempts will be made to provide assistance in emergency evacuations, however this service is not guaranteed. If transportation is available, all attempts will be made to give advance notice by phone of the date and time to expect to be picked up for transport to a shelter. IF I DECLINE TRANSPORTATION when the transporter arrives, I understand that I may not have another opportunity to request this service. I understand that this survey is voluntary and this information will be maintained at the Park County Office of Emergency Management. I also understand this information may be used during the planning process for emergency evacuations. Signature of Registrant or Legal Guardian Date