Social Needs Registry Form


Social Needs Registry Form

 
Please be as complete as possible in your responses.
 
* = Required Fields

Organizational Information

Please indicate your organization's willingness to take part in any or all of the following activities:*
 
Pre-Emergency Planning:
Organization or faith based communities can play a powerful role by encouraging customers, members and others with whom they have a trusted relationship to prepare for emergencies. Since emergency incidents can occur quickly and without warning, planning for any emergency requires considering all likely scenarios. Being prepared can reduce fear, anxiety, and losses that accompany disasters. Your organization can assist with communicating emergency preparedness information provided by Fairfax County to your constituents. Is your organization willing to distribute emergency preparedness information?
 
Response:
During an emergency, organizations may partner with the County by making resources available to emergency planners and responders. An inventory of resources available to assist vulnerable, at-risk and hard to reach residents will greatly assist the County respond to emergencies. Registration with the Community Emergency Alert Network is required for participation in this phase. Please indicate any resource that can be made available:
 
(select all that apply)







If Other, then specify: 
 
Recovery:
Following an emergency organization can assist with communicating steps to prevent or reduce future losses as well as providing resources to assist residents with the repair of damaged property. Registration with the Community Emergency Alert Network is required for participation in this phase. Please indicate any resource that can be made available:
 
(select all that apply)







If Other, then specify: 
Organization Name:*
Street Address:*
   Number: Street Name:  Type: 
   Line 2:
   City: State:  Zip Code: 
Mailing Address: (if different from street address)
   Number: Street Name:  Type: 
   Line 2:
   City: State:  Zip Code: 
Phone:* - -
TTY: - -
FAX: - -
E-mail:*
Mission:*
Organization Type:*(select one)






If Other, then specify:
 
Social Need Population Served Annually:*(select all that apply)
Number of people served (if known):
(0-1,000,000)
 
 
Number of people served (if known):
 
Number of people served (if known):
 
Number of people served (if known):
 
Number of people served (if known):
 
Number of people served (if known):
 
Number of people served (if known):
 
Number of people served (if known):
 
Number of people served (if known):
  Age
 
Number of people served (if known):
 
Number of people served (if known):
 
Number of people served (if known):
  Economically Disadvantaged
Number of people served (if known):
  Public Transportation Dependent
Number of people served (if known):
  Isolated by Culture or Religion
Number of people served (if known):
  Digital Divide Barrier
Number of people served (if known):
  Household Pets and Service Animals
Number of people served (if known):
  Licensed Facilities
Number of people served (if known):
Supervisory District Served:*
(select all that apply)








Contact Information for your Organization

Please enter up to three representatives from your organization that will be the primary contacts for receipt of emergency preparedness, response and recovery communications.
 
Contact 1:
    First Name:*
    Middle Initial:
    Last Name:*
Title:*
Phone Numbers:
    Primary:* - - Extn:
    TTY: - -
    Cell: - -
E-mail:
 
Contact 2:
    First Name:
    Middle Initial:
    Last Name:
Title:
Phone Numbers:
    Primary: - - Extn:
    TTY: - -
    Cell: - -
E-mail:
 
Contact 3:
    First Name:
    Middle Initial:
    Last Name:
Title:
Phone Numbers:
    Primary: - - Extn:
    TTY: - -
    Cell: - -
E-mail:

Disclosure Certification

Organization permits Fairfax County to utilize this contact information for communication related to other county services and programs (not related to emergency).*
 
Organization permits Fairfax County to share this information with partner agencies and organizations such as the Red Cross.*
 
Organization acknowledges that Fairfax County may be required by FOIA or other law to release this information. By submitting this information, I acknowledge that I am authorized to act on behalf of my organization and that my organization authorizes the release of this information for Social Needs Registry communications.
 
    

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