1. What is/are the full name(s) of the vulnerable person(s) who reside in your household?

2. What is your 911 address?

4. If you have one, please provide your email address.

5. How best can we contact you in an emergency? Please provide details for such contact.

6. What is the nature of yours or your household members’ vulnerability - what are yours/their limitations?

7. In an emergency would you or your vulnerable household member be able to self-evacuate? (self-evacuate means that you would be able to leave your location, without the need for outside help) Yes No

8. Name of the person who completed and submitted this survey.

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