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Washington Parish Council On Aging & Public Transit

Diaster Prepardness Survey Form
for Elderly and Special Needs Individuals

   Date:    


   Last Name:       First Name:      MI: 
   Age:      DOB (mm/dd/yyyy):     Sex: (M/F)nbsp;    SSN:     


   Apartment or Complex Name:    
   Physical Address:      Apartment Number:  
   City:      State:     ZipCode:    

    Mailing Address:     
    (If different from above)
   City:      State:     ZipCode:    

   Telephone Number:    

   Language Spoken In House:    

   Next of Kin:  
   Relationship:  
   Address:  
   Home Phone:  
   Work Phone:  
   Other:  
Can You Care For Yourself? (Y/N):  
   If Not, Who Does?:  
Relationship:  
Address:  
Work Phone:  
Home Phone:  
   Home Health? (Y/N):  
   Home Health Agency:  

   DAILY NEEDS (Y/N)

   Oxygen?   Dialysis?   Dressings?
   Airway Suction?   Cathether?  

   Special Feeding Equipment?

   MOBILITY (Y/N)

   Walks?   Walks with assistance?
   Wheelchair?   Bedridden?
OTHER DISABILITIES (Y/N)

Deep Wound?   Chronic Infection?
Wheelchair?   Other:

Special Requirements not listed above


Transportation needed to evacuate (Y/N)

Ambulance     Handicap Van     Car  

Need electrical power for medical equipment?




   Do you plan to evacuate?


        

You can call us at

Public Transit
(985) 732-6868
       
(985) 732-6671

Council on Aging
(985) 839-4535

or eMail us at washcoa@bellsouth.net


Links

Medicare       
AARP       
Capital Area Agency On Aging       
LaSHIP        
City of Bogalusa, La.        
Disaster Survey Form
Center News