Carter County Special Needs Registration

The Carter County Health Center along with the Carter County Emergency Management Agency  is developing a registry of individuals with Special Healthcare Needs who may require special assistance in the event of a disaster such as a tornado, severe storm, flood or earthquake.

Examples of Special Healthcare Needs are individuals:

·         With severe respiratory problems (oxygen or ventilator dependent) that require a power source or ambu bag

·         Dependent on airway suctioning (tracheotomy)

·         On IV (intravenous) therapy

·         Require tube feedings

·         Require wound care or help with injections on a daily basis

·         With physical or mental conditions that require daily medication

·         Language or cultural barrier

·         Hearing or Speech Impairment

This is a voluntary registration. The information you provide will be confidential and will be used by emergency personnel only to determine our community’s needs in the event of a disaster. In an emergency event you may be contacted via telephone, by an in-office staff or automated message, or by text message.  Should you wish to be included in the registry, please complete the questionnaire.

If there are any questions, feel free to call the Carter County Health Center at 573-323-4413.

 

**If you have already registered. Please update your information and submit to keep your name on the registry.

Sign in to Google to save your progress. Learn more
Name:  *
Age: *
Address: *
Please also provide directions to your home if you believe tht would be helpful. 
City: *
Zip Code: *
Phone number:  *
Emergency contact person: *
Emergency contact phone number: *
Do you live in a:  *
Are you home bound?  *
Do you have any medical equipment that requires power?  *
If you do have medical equipment that needs power please explain:  *
Enter NA if this does not apply to you
Medical Needs: Please Check all that apply *
Required
Do you currently take meedications for (please check all that apply) *
Required
Do you have an agency that currently visits your home? *
If so, who? 
Phone number of agency:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Carter County Health Center. Report Abuse
Google Forms