9-1-1 QUESTIONNAIRE

9-1-1 QUESTIONNAIRE

ADDRESS:____________________________________________________________________________________

PHONE NUMBER______________________________________________________________________________

LIST INFORMATION BELOW FOR YOURSELF AND ALL PERSONS LIVING IN HOUSEHOLD:

NAME-FIRST, LAST DATE OF BIRTH DOCTOR AND PHONE NUMBER

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YES HANDICAPPED PERSON (NAME AND HANDICAP)___________________________________________

YES DIABETIC (INSULIN DEPENDENT YES/NO) NAME:___________________________________________

YES HEART PATIENT NAME:_______________________________________________________________

YES SERIOUS DRUG/ALLERGIES (NAME AND ALLERGY) _______________________________________

YES FARM CHEMICALS (STORAGE LOCATION)________________________________________________

YES PROPANE TANK (LOCATION)____________________________________________________________

PLEASE LIST ANY INFORMATION IMPORTANT TO EMERGENCY RESPONDERS_____________________

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PERSON(S) LIVING OUTSIDE HOUSEHOLD TO NOTIFY IN EMERGENCY (NAME/PHONE NUMBER)

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PROVIDE DIRECTIONS TO YOUR HOME (STARTING IN METROPOLIS)___________________________

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I AGREE TO NOTIFY MASSAC COUNTY 911 OF ANY CHANGE IN THE ABOVE INFORMATION, AND AGREE THAT MASSAC COUNTY 911 CLAIMS NO LIABILITY FOR ERRORS OR OMMISSIONS IN THE CONTENTS OR USE OF INFORMATION SUBMITTED ON THIS QUESTIONNAIRE.

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SIGNATURE DATE