Disclaimer: all information is provided for SCVFD use only.  It will not be given out as public information.

1 -  Print Screen or Download

2 -  fill out questionnaire

3 -  Mail to:   Attention: Director of Evacuation Resources for the SCVFD

     P. O. Box 2673 Cupertino, CA  95015

Important  - Keep this information current!

RESIDENT:

Name: _______________________________________________________________

Address: _____________________________________________________________

Home Phone #:________________________________________________________ 

Cell Phone #:___________________Work Phone #:___________________________

E-mail:_______________________________________________________________

Name: _______________________________________________________________

Address: _____________________________________________________________

Home Phone #:________________________________________________________ 

Cell Phone #:___________________Work Phone #:___________________________

E-mail:_______________________________________________________________

____ List the number of people in residence during the day.

____ List the number of people in residence during the evening.

SPECIAL NEEDS:

Please list transportation needs (wheelchair, walker, oxygen and/or confined to bed). ___________________________________________________________________

___________________________________________________________________

Are prescription medications stored in a container in the refrigerator?

Yes___ No ___

Location of refrigerator if not in the kitchen.____________________

Other areas prescription medicines are located._______________________________

_____________________________________________________________________

List the number and kinds of pets/livestock; special handling needs, their location and temperament.

_____________________________________________________________________

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Do you have a trailer for transporting livestock? Yes___ No___ If yes, location. _____________________________________________________________________

SPECIAL HAZARDS:

Circle the amount

Propane (lot/little/none)

Location: _____________________________________________________________

Gasoline (lot/little/none)

Location: _____________________________________________________________

Diesel (lot/little/none)

Location: _____________________________________________________________

Pesticides (lot/little/none)

Location: _____________________________________________________________

Compressed Gas (lot/little/none)

Location: _____________________________________________________________

Ammunition/Explosives (lot/little/none)

Location: _____________________________________________________________

Other Special Hazards (lot/little/none)

List/Location: _________________________________________________________

_____________________________________________________________________

SPECIAL PROPERTY FEATURES:

Check those conditions that apply.

___ Barn

___ Bunker

___ Corral

___ *Fire Pump

___ *Fire Turn Around

___ Generator

___ *Hydrant

___ Horse Trailer

___ Large cleared area

___ Narrow unrated bridge

___ Narrow, long, steep driveway (dirt/paved?)

___ Outbuilding

___ *Swimming Pool

___ *Water Storage/Supply

___ Water Truck

___ Other: _______________________________________________________

SPECIAL SKILLS:

Check applicable skills and name of person trained in the skill.

___ CPR  _______________________________________________________

___ Equipment Operator (specifics) ___________________________________

___ Fire Fighting  _________________________________________________

___ First Aid  ____________________________________________________

___ Ham Radio  __________________________________________________

___ Other Medical (specifics)  _______________________________________

___ Other  _______________________________________________________

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list your five closest neighbors to your home: ______________________________________________________________

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Phone tree: List the name and numbers of 5 of your neighbors that you will contact in an emergency.

__________________________________________________________________

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* information related to fire fighting