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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 (check all that apply)
  • 2+ Story
  • Access to Windows PC
  • Apartment/Condo
  • Attached Garage
  • Basement
  • Fireplace
  • Fireplace/Wood Stove
  • Mobile Home
  • Natural Gas/Liquid Propane/Kerosene
  • One-Story

How did you hear about Safe Escape? - Check all that Apply
  • Clinic/Physician
  • Family/Friend
  • Support Group
  • Flyer
  • E-mail/Internet
  • Newspaper
  • 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) - Check 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) - Check all that Apply

  • Any Emergency
  • Avalanche
  • Biological Hazard
  • Blizzard
  • Building Fire
  • Chemical Leak
  • Contacting Emergency Services
  • Contamination
  • Drought
  • Earthquake
  • Excessive Heat
  • Extreme Cold
  • Flooding
  • Having Child Identification
  • Having Medical Records
  • Having Medicines
  • Having Necessary Medical Equipment
  • House Fire
  • Hurricane
  • Ice Storm
  • Keeping Track of Child
  • Landslide
  • Security Emergency
  • Tornado
  • Transporting to Safe Area
  • Tsunami
  • Typhoon
  • Volcanic Eruption
  • Wildfire

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

Special Thanks: US Department of Homeland Security Assistance to Firefighters Program · Safe Escape Sponsors

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