Medical Needs Registry Form - Help & Explanatory Information
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If you are not able to use this form to provide information and do not have someone who can help you fill this out, please call (703)324-9000, TTY (703)324-9001.
Explanatory Information for Questions on the Medical Registry Form
Phone Numbers (Primary): Phone number where you can be reached the majority of the time, for example a home phone, cell phone or TTY. This number will also be used to contact you to verify the information that you have provided. This number will also be used during emergencies.
Phone Numbers (Secondary): Secondary phone number where you may be reached for example this may be your cell phone number or work number. This number may be used to contact you to verify information that you have provided.
Residence Type: This information will be used during emergencies. Knowing the type of home you live in will ensure that your residence is easily identifiable and proper resources are sent to your address during the evacuation process.
Do you have a Service Animal?: A service animal is any guide dog, signal dog, or other animal individually trained to do work or perform tasks for the benefit of an individual with a disability. Work of a service animal includes, but is not limited to, guiding individuals with impaired vision, alerting individuals with impaired hearing to intruders or sounds, providing minimal protection or rescue work, pulling a wheelchair, or fetching dropped items.
Owners will not be separated from their service animals. It is important that owners prepare for their service animals' needs during emergencies by having a three day supply of food, water and other items readily available.
Number of Household Pets: A household pet is a domesticated animal, such as a dog, cat, bird, rodent (including a rabbit), or turtle that is traditionally kept in the home for pleasure rather than for commercial purposes and can travel in commercial carriers and be housed in temporary facilities. Household pets do not include reptiles (except turtles), amphibians, fish, insects/arachnids, farm animals (including horses), and animals kept for racing purposes.
If necessary household pets may accompany individuals with medical needs to a shelter site. There is no guarantee that the animal will remain with the owner as it may be necessary to shelter the animal at a different location. It is important that owners prepare for their household pets' needs during emergencies by having a three day supply of food, water and other items readily available. Also should transportation be necessary cages will be required for felines and a muzzle, leash and collar will be required for canines.
Do you currently use public transportation (Fastran, MetroAccess, bus, rail, taxi)?: This information will assist in planning for an evacuation. If you use public transportation regularly planners will be better able to determine your transportation means.
Do you have or can you arrange your own transportation?: Medical shelter locations will be announced by the Office of Public Affairs using media outlets. These announcements will provide the location of the medical shelter so individuals providing their own transportation will know where to go.
Can you sit in a regular car/bus/van seat?: This information will assist transportation planners in meeting your needs during an emergency. It will be used to ensure that the most appropriate vehicle available is dispatched to your location for evacuation.
Can you independently transfer to/from a wheelchair?: This information will assist transportation planners in meeting your needs during an emergency. It will be used to ensure that the most appropriate vehicle available is dispatched to your location for evacuation.
Will a caregiver/companion accompany you to the shelter?: If you require assistance from a caregiver or companion it is recommended that they accompany you to shelter and be prepared to provide assistance to you during your stay. Caregivers or companions should also bring a three day supply of food, water and medication as well as a change of clothes and bedding for their personal use.
Only individuals with medical needs and their caregivers and dependent children will be admitted to medical shelters. Minor children will be permitted to stay in the medical needs shelter with their parents, guardians or caregivers who are residing there. Additionally, if the caregiver of the person with medical needs has minor children, they also will be permitted to bring their children with them to the shelter. However, the shelter will not be equipped to provide child care services for the children staying in the shelter. Parents/caregivers will (continue to) be responsible for supervising and caring for their own children just as they were in their home prior to the emergency situation.
Name of emergency contact: The individual identified will be contacted only during an actual emergency. There will be no routine contact made. Emergency contact individual identified should be aware that the name is being disclosed.
What is the name of your home health care agency?: If you routinely receive assistance from a home care agency is anticipated that they will provide this care in the medical shelter. The agency will be contacted and made aware of your presence in the medical shelter and arrangements made for them to provide care to you at that location. Please bring the home care agency phone number and contact information with you. You should inform the agency of your intent to seek shelter in a medical shelter during an emergency.
What is the name of your medical equipment supplier(s)?: This information will be used for planning purpose and in the rendering of services the medical shelter. Please bring the medical equipment supplier phone number and contact information with you.
Is your medical condition temporary: This information will be helpful in maintaining the registry. You will be contacted for verification purposes prior to our medical release date or at least annually to determine your need for a medical shelter. Once your need for a medical shelter has been established you will not be deleted from the registry until you have been contacted and informed of this decision.
Check all that apply to your condition: Fairfax County staff and contractors will use this information to meet your needs during your stay in the medical shelter. This information will assist when staffing requirements are being determined and when equipment is ordered for the shelter.
Weigh over 300 lbs: This information is important for ordering the correct size equipment such as cots at the shelter site and for arranging transportation to ensure the proper vehicle is dispatched to your location.
Are you dependent on any of the following: This information will be used by shelter staff to determine the equipment and power needs at the shelter site. If you routinely use a device such as a CPAP machine, plan on bringing your equipment with you to the shelter.
Prescription Medication: It is important that you bring a three-day supply of your medications, preferably in their original bottle, with you to the shelter. You should also bring a list of the medications that you are currently taking, and the phone numbers of your physician and pharmacy.
Mobility: This refers to equipment that you use routinely. You are strongly encouraged to bring your own equipment to the medical shelter. Prior knowledge of your equipment usage will assist staff in planning for space and power needs. There will be limited equipment available at the shelter site.
Who should be contacted for verification of information on this form?: Once we receive your information you will be contacted to verify the information that has been entered and to clarify any questions staff may have about care.