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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.