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Needs Assessment

Step 1: Household and Background Information

Complete this form to help us determine the products and services which best suit your needs.

Home/Home Life
*Home Characteristics (select all that apply)
  • 1 Story House
  • 2+ Story House
  • Access to Windows PC
  • Apartment/Condo
  • Attached Garage
  • Basement
  • Fireplace/Wood Stove
  • Mobile Home
  • Natural Gas/Liquid Propane/Kerosene


*How did you hear about Safe Escape? (select all that apply)
  • Clinic/Physician
  • Family/Friend
  • Support Group
  • Flyer
  • E-mail/Internet
  • Search Engines:
    • Google
    • Yahoo
    • MSN
  • Newspaper
  • Hospital Website
  • Other
    • English
    • Spanish
    • American Sign Language
    • Other



  • Male     Female




  • Yes     No
  • Yes     No
  • Yes     No

  • Yes     No
  • Yes     No
  • Yes     No
  • Yes     No

Products

Tell us which types of products would be helpful in evacuating your child(ren) (select all that apply)

  • Child ID & Medical Alert
  • Child Tracking Products
  • Communication Devices
  • Emergency Lighting
  • Medication Storage
  • Mobility and Transfer Devices
  • Personal Protective Equipment

Emergency Situations

Tell us which situations concern you when evacuating your child(ren) (select all that apply)

  • Avalanche
  • Biological Hazard
  • Blizzard/Winter Storm/Ice Storm
  • Chemical Leak/Poisonous Gas
  • Drought
  • Earthquake
  • Extreme Cold
  • Extreme Heat
  • Flooding
  • House Fire/Building Fire
  • Hurricane/Typhoon
  • Landslide
  • Security Emergency
  • Tornado/High Wind
  • Tsunami
  • Volcanic Eruption
  • Wildfire

Has Your Family Experienced One or More of the Above Emergencies?* Yes     No

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* Denotes required field