Emergency Management Survey Form

Please Answer All Questions Completely

Dear Resident,

Disaster can strike at any moment. We all have a responsibility to be ready. The Borough of Yeadon is required to ensure disaster preparedness for our community. We are asking you to complete this form to help us protect you and your family. The information will be used for the sole purpose of the Yeadon Emergency Management Agency. With this information we can assess the needs of our community in the event of a disaster, whether manmade or natural, and take steps to reduce loss of lives and property. Please take a few minutes to complete. Thank you.

All information is confidential and protected under the HIPAA Act of 1999.
If you have any questions about this form please call 610-623-2392.

1. Home Address

2. Home Phone

Cell Phone

3. List each person living in the home
(including yourself)

A.




B.




C.




D.




E.




F.




4. Are any of the above individuals impaired or handicap?
 Yes
 No

5. If yes, please list by name those who are impaired or handicapped and state the nature of their situation
(blindness, paralysis, mental illness etc.)




6. Please indicate whether there is anyone who may require special attention
(i.e. heart, kidney lung problems etc)

7. Is there anyone who speaks a language other than English?
 Yes
 No

If yes, what language?

8. Family Physician

Phone #

9. Name, address and telephone number of nearest out-of-town relative/emergency contact(s)

10. Email Address

Anti-Spam
check box please