| Southborough Emergency Management | |||
| 2008 Emergency Planning Survey | |||
| The EMD/LEPC is dedicated to ensuring the privacy and confidentiality of persons and their medical | |||
| information. The information provided will be used solely for the purposes of ensuring a quick response | |||
| to you in the time of need and providing the best care. | |||
| Fill out one form for every family member that requires assistance | |||
| If none, fill out one for each family, noting number of family members | |||
| Name | Date of Birth | ||
| Street | Telephone | ||
| Emergency contact | Emergency contact phone | ||
| Primary Doctor | Doctor’s Phone # | ||
| Pharmacy Name | Pharmacy’s Town | ||
| I understand that I am not required to fill out or return this form. | |||
| I give permission for the information I provide on this form to be used for Southborough’s emergency and disaster management planning. | |||
| I understand this information may be shared with the police and fire departments. | |||
| SIGN HERE:____________________________________ Date:____________________ | |||
| Check if true | My own emergency Preparation | Check if true | IF I WAS TOLD TO LEAVE MY HOME BECAUSE OF AN EMERGENCY: |
| ( ) | I have a File of Life posted on my refrigerator. | ( ) | I would stay with family or friends outside of Southborough. |
| ( ) | I have a smoke detector on every level of my home. | ( ) | I would go to a hotel/motel. |
| ( ) | I have a carbon monoxide detector on every level of my home. | ( ) | I would rely on Southborough to provide a shelter. |
| ( ) | The street number on my house is easy to see from the street at night. | ( ) | I would need help to leave my home. I can ride in a regular van. |
| ( ) | My house is hard to find. | ( ) | I would need help to leave my home. I need a wheelchair van. |
| ( ) | I would need help if my electricity didn’t work for a few days. (no lights or TV, no stove or heat) | ( ) | I would need help to leave my home. I use special medical equipment and need an ambulance. |
| ( ) | I have an emergency plan for my pet. | ( ) | I know what to take with me. |
| ( ) | I have a service animal/pet. | ( ) | I would never leave my home. |
| ( ) | I have an emergency kit (flashlight, radio, batteries, and other items). | ( ) | I cannot order new prescriptions unless I am almost done with the current one. |
| ( ) | I know how to shelter-in-place in my own home. | ( ) | I rely on street drugs or alcohol, therefore need special care in a shelter. |
| Check if true | MY HEALTH | Check if true | MY HEALTH |
| ( ) | I use life saving prescriptions. | ( ) | I use a feeding tube. |
| ( ) | I need a medically prescribed diet. | ( ) | I use life support equipment. |
| ( ) | I use a dialysis machine at home. | ( ) | I use a suction unit. |
| ( ) | I get dialysis at a medical facility. | ( ) | I use an oxygen unit. |
| ( ) | I have trouble getting out to shop for food and other necessary things. | ( ) | I rely on medical equipment that requires electricity. |
| ( ) | I get so cold in the winter, I worry I will get sick. | ( ) | I rely on equipment that requires electricity but I do not have a backup generator. |
| ( ) | I get so hot in the summer, I worry I will get sick. | ( ) | I need help with daily living activities. (dressing, eating, toileting) |
| ( ) | I would like Meals-on-Wheels to deliver meals to me. | ( ) | I have a caregiver, someone takes care of me part or all of the time. |
| ( ) | I have a mental health issue. | ( ) | No one checks on me. I could be very sick and no one would know it. |
| ( ) | I communicate with a TDD. | ( ) | I have a family member who wanders away from home. |
| ( ) | I need a TDD. | ( ) | I need help with my children. |
| ( ) | I communicate by fax. My number is: | ( ) | I am a senior citizen and I am bringing up my grandchildren. |
| ( ) | I have severe or life threatening allergies. | ( ) | I am a caregiver, I take care of another person. |
| ( ) | I have a contagious condition or disease. | ( ) | I take care of another person and it is wearing me out. |
| ( ) | I use a hearing aid /cochlear implant (HA/CI) telephone device. | ( ) | I would like to volunteer. Please call me (or contact the EMD office) |
| ( ) | I have an impairment that makes receiving emergency information difficult. | ( ) | It is OK for someone to call me if additional information is needed. |
| ( ) | I attached additional information | ( ) | I need special care, please call me. |
| Comments: | |||
| “Thank you for taking the time to help us help you”. | |||