Texas Counties Deliver – learn how county government serves you

Emergency Management Citizen's Form

Click on link below for a printable form
Emergency Management Citizen's Form

Full Name
Physical Street Address
Phone Number
Emergency Contact Name and Number
Emergency Contact Relationship To You
Do you have a Caregiver? If yes, provide name of Caregiver and Caregiver phone number.
Do you have any disabilities or medical conditions that would prevent you from evacuating on your own in case of an emergency?
Do you have transportation to evacuate in case of emergency? If no, do you need transportation assistance to get to a local evacuation point or shelter in case of emergency?
How many people live in your residence?
Do you need transportation assistance to get to a local evacuation point or shelter in case of emergency?
Have you been diagnosed with Dementia/Alzheimer's Disease?
Have you been diagnosed with a debilitating chronic illness?
Do you receive Dialysis?
Do you have a medical condition that requires 24-hour supervision from a skilled Nurse?
In the event of power outage, will you have heat and/or cooling?
Do you have life sustaining medical devices that require power? (Examples would include a breathing machine, suction unit, oxygen concentrator, ventilator or feeding pump)
How many hours of power are provided by your back-up battery power source?
Do you receive critical medical treatment from a Nurse or Doctor at your home or in a Doctor's Office more than twice a week?
Do you require help conducting daily living activities such as bathing, eating, walking, toileting? Your answer helps improver shelter plans.
Do you have any medical equipment that would need to be evacuated with you? (Example would be a wheelchair, walker, oxygen concentrator, etc...)
Who is your primary care provider?
Do you have a storm cellar?
Do you have a basement or safe room?
Do you have any pets that live in your residence? If yes, what pets live in your residence and do you have pet carriers for all your pets?
Any other conditions, comments or notes that we should enter into your records?