Evacuation Survey

Residential Care Facility Evacuation Survey

Please complete the survey below with your facility’s current situation. Please don’t type your password and click the Update Survey button unless you are updating an existing survey.

This information is preliminary, but extremely important and will be used to formulate an evacuation plan. You will have the ability to change that information as your facility’s needs change. We will send out reminders once a year to update the information. If you think it’s necessary to update the information prior to the annual update, you can do so by entering your password and clicking on the “Update Survey ” button. You should be directed to the last version of your survey and you can change any or all of the information. Be sure to click on the submit button at the bottom of the page when you have completed the modifications to your information. An email notification will be sent to the ADA Coordinator when a change has been made and submitted.

Fill out the form below for a new quesionnaire. If you have an update, enter your password and click the Update Survey button below. If you can't remember your password, email Chuck Kempf and your password will be emailed back to you.

Password:

New Facility Survey

Email Address:
Password:
Name of facility:
Street Address:
City:
State:
Zipcode:
Mailing Street Address:
Mailing City:
Maling State:
Mailing Zipcode:
Phone number:
Name of primary contact:
Cell phone number:
Name of alternate contact:
Alternate cell phone number:

Total number of residents:

Number of residents needing evacuation assistance:

Number of residents with mobility devices (scooters, wheelchairs, wlakers, etc.):

Does an alternate plan exist if the city couldn't assist for the first 24 hours?:		Yes No

Will your facility be able to provide staff to assist in transporting and caring for residents?:		Yes No

Approximately how many staff members will be available:

If evacuation was not necessary, but leaving the facility wasn't an option, how long would supplies last to take care of residents and employees?:

Special instructions: