SHREWSBURY EMERGENCY MANAGEMENT

INFORMATION SHEET 

Do you or anyone living in your household have any disabilities?  Yes:                 No:                

Physically Disabled:                  Developmentally Disabled:                    Dialysis Treatments:                 

Visually Impaired:                     Legally Blind:                Hard of Hearing:                     

Bed Ridden:                 Asthma or Allergies requiring medicine on a daily/regular basis:              

Do you or anyone living in your household require any special equipment? Yes:  No     

Lift Van:             Wheel Chair:              Oxygen Tanks:            Dialysis Machine:                    

Walker or Cane:           Guide Dog:                  Respirator:                   TTY or Teletype                     

Medicines or Inhalers:                             Oxygen Concentrator:            

Ambulance: (Individuals cannot ride in bus/car or van):                                     

Other:                                                                                                                                                  

                                                                                                                                                           

If Yes, please list their names and age:

Name:                                                  Age:                Requirements:                                                 

Name:                                                  Age:                Requirements:                                                 

Name:                                                  Age:                Requirements:                                                 

Name:                                                  Age:                Requirements:                                                 

 

Any person who requires medications be transported with them should store those medications in a manner that allows responders to rapidly access and transport them as they are assisting the individual during an evacuation. 

Can everyone (Adults) in your house understand English?  Yes:      No:               

Which Language do you understand?                           

 

IF YOU ANSWERED ANY OF THE QUESTIONS ABOVE, PLEASE COMPLETE THE

FOLLOWING AND RETURN TO THE SHREWSBURY BOROUGH OFFICE

C/O EMERGENCY MANAGEMENT TEAM, 35 W. RAILROAD AVE.

 

The Shrewsbury Firehouse siren currently blows only once per cycle, for approximately 8 to 12 seconds at approximately 3 minute intervals between soundings, for fire and emergency medical dispatches.  If you hear the Firehouse siren blowing continuously or cycling up and down many times in succession, tune your AM broadcast radio to WSBA 910 for emergency information and instructions.

 

Name:                                                              Address:                                                                                  

Apartment or Unit #:                             Telephone #:                                         Is it Unlisted?                           

How many individuals live in your household (including all adults & children):                                          

Name of Person completing this form:                                                              

Relationship/Position:                                                    Date Completed:                                            

Note: This information is considered confidential and will only be used for emergency purposes. You will be contacted by the Emergency Management Personnel to better serve you in the event of an emergency.