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Emergency Management Assistance Survey

  1. Hearing Disability:*

  2. Special Phone Equipment Installed:*

  3. Sight Disability:*

  4. Physical Disability (require assistance walking?)*

  5. Special Equipment Needed (wheel chair, walker, etc):*

  6. Respiratory Disability:

  7. Oxygen Assistance:*

  8. Ventilator Assistance:*

  9. Language Translator Needed?*

  10. Do you have "Vial of Life?"

  11. Leave This Blank:

  12. This field is not part of the form submission.