LAST NAME:

BIRTH DATE:

(mm/dd/yyyy)

FIRST NAME:

AGE:

ADDRESS:

CITY:

STATE:

ZIP CODE:

APT:

PO BOX

CITY:

STATE:

ZIP CODE:

LIVE ALONE:

Yes No

NAME OF COMPLEX:

HOW MANY STORY(S)

One Two Three Four

PHONE NO:

WEIGHT:

lbs

HEIGHT:

LANGUAGE:

English Spanish Bi-Lingual

CONSTRUCTION:

Wood Frame Block Not Sure

TYPE OF HOME:

Single Family Mobile Home Apartment

LOCAL EMERGENCY CONTACT PERSON:

PHONE NUMBER:

PRIMARY DOCTOR:

PHONE NUMBER

NAME OF HOME HEALTH / HOSPICE / NURSING AGENCY:

NAME OF EQUIPMENT / SUPPLY PROVIDER:

WILL YOU NEED EVACUATION TRANSPORTATION?

Yes No

IF YES, WHAT KIND OF TRANSPORTATION?

N/A Ambulance Standard Vehicle Stretcher Vehicle Wheelchair Vehicle

PLEASE SELECT THE TYPE OF TRANSPORTATION ASSISTANCE YOU REQUIRE:

IS TRANSPORTATION NEEDED?

No Transportation To Special Needs Shelter To Nursing Home / Hospital

CAN YOU LAY FLAT?

No Yes

NEED ASSISTANCE ENTERING/EXITING A VEHICLE?

No Yes

SKIN INFECTIONS

HEART CONDITIONS:

(type:)

N/A Stable CHF

DEMENTIA (early):

HIGH BLOOD PRESSURE:

ARTHRITIS:

SKIN DISEASE:

SEIZURES (controlled):

OSTOMY:

(type):

ASTHMA:

DIABETES:

KIDNEY DISEASE (stable):

BRONCHITIS:

EDEMA:

EMPHYSEMA / COPD:

MUSCULAR DYSTROPHY (MD):

HIP / KNEE REPLACEMENT (less than 6 months):

STROKE/CVA (limitations)

CEREBRAL PALSY (CP):

OPEN SORES:

APHASIA:

NEBULIZER:

OXYGEN USE:

MULTIPLE SCLEROSIS (MS):

COMATOSE:

DEMENTIA (moderate to late):

PARKINSON'S DISEASE (early):

PARKINSON'S DISEASE (advanced):

MEDICAL EQUIPMENT (IV, tube, feeder, indwelling catheter):

SPECIAL DIET (Bring any doctor prescribed food items with you when you evacuate):

PSYCHOSIS:

DIALYSIS:

HOSPICE:

UNSTABLE HEART CONDITION:

SEIZURES (uncontrolled):

CONTAGIOUS DISEASE:

IF YES, NAME:

BLIND:

HEARING IMPAIRED:

SERVICE ANIMAL:

VISION IMPAIRED:

LEGALLY BLIND:

GLASSES:

OTHER MEDICAL CONDITIONS / COMMENTS:

MEDICATION (please remember that medicine will need to be in the original bottle):

ELECTRICAL NEEDED:

No Yes

FOOD OR DRUG ALLERGIES:

No Yes

IF YES, PLEASE STATE:

I WALK WITHOUT HELP:

Yes No

I CAN GO TO THE RESTROOM ALONE:

Yes No

I USE A WHEELCHAIR:

Yes No

I USE A WALKER:

Yes No

I OWN A WHEELCHAIR:

Yes No

I AM BEDRIDDEN:

Yes No

I USE A CANE:

Yes No

I CAN FEED MYSELF

Yes No

I AM WHEELCHAIR BOUND:

Yes No

I HAVE SOMEONE ASSIST ME WITH ALL MY DAILY ACTIVITIES:

Yes No

PEOPLE TO ACCOMPANY YOU TO THE SHELTER:

PHONE:

DIRECTIONS TO HOME:

COMMENTS:

DO YOU OWN A DNR (Do Not Resuscitate):

Yes No

IF YES, BRING WITH YOU TO SHELTER.

To the best of my knowledge, I certify that this information contained herein is true and correct. I understand that based on the data I have provided, the Hardee County Emergency Management Department in consultation with the Hardee County Health Department will determined which evacuation assistance, if any, this program may be able to provide.

The law permits Hardee County Government, Emergency Services to use and disclose my protected health information, for treatment, payment and health care operations.  Understanding the PSN evacuation program is provided at no charge, I also accept responsibility for all expenses associated with any extenuating medical issues that arise.

Electronic submission of this form is understood and comparable to a real signature. The Hardee County Emergency Management Department or any other agency using the provided information cannot be held responsible for any inaccurate, incorrect or false information that has been entered into this form.

NAME:

If the person completing this form is NOT the applicant, please answer the following:

NAME:

PHONE:

RELATIONSHIP / AGENCY: