Family/Resident Safety Survey
1.
What is your name? (This information is kept confidential)
2.
What is your street address? (Please include City and Zip) (This information is kept confidential)
3.
What is your phone number? (This information is kept confidential)
4.
How many individuals live at this residence?
5.
Check all boxes that apply to your residence:
Someone at this residence is blind or visually impaired
Someone at this residence has a cognitive impairment that may involve memory, language, thinking and judgement issues
Someone at this location is hard of hearing or deaf
Someone at this residence is physically linked to medical equipment required to sustain their life and said equipment is dependent on publicly supplied electricity
Someone at this residence is bedridden, uses a wheelchair or has a mobility impairment
Someone at this residence has a fall-risk
Someone at this residence is highly overweight (assistance would be required in the event of a lift-assist or fall)
Someone at this residence has a psychiatric impairment
Someone at this residence has a speech impairment
Someone at this residence may be using an electronic device for text communication utilizing a telephone line (TTY/TTD Machine)
Someone at this location suffers from PTSD
Someone at this residence has suicidal thoughts/tendencies
Someone at this residence is known to abuse drugs and/or alcohol
Someone at this residence is known to have violent tendencies
Someone at this residence possesses weapons
There is an aggressive animal at this residence
Any other information we should know about the resident(s) of this address.
6.
Does someone at this residence have a medical alarm system (Lifeline, Lifealert, etc.)?
Yes
No
If Yes, please include the name and number of the service used.
7.
Does this residence have an alarm system?
Yes
No
If Yes, please include the name and number of the service used.
8.
Does this residence have a lockbox/keypad/gate entry code or Knoxbox?
Yes
No
If Yes, please provide location and code here, as this will assist emergency services in arriving quicker and more efficient in the case of an emergency.
9.
Do you have any other pertinent information about your residence/property or the people/animals that live there that we should know about?
10.
Is your home over 3500 square feet?
Yes
No
11.
How do you heat your home? (Check all that apply)
Wood
Propane
Natural Gas
Electric
12.
Does your family have a Severe Weather Shelter/Room that you use in the event of such occurrences? If so, where do you go? (I.e. bathroom, storm shelter, panic room, etc.).
Current Progress,
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