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Emergency Response Information Survey

  1. All responses are confidential, and will assist Police, Fire and EMS in responding to your emergency.
  2. Owner or Tenant
  3. Do you use an oxygen system in your home?
  4. If yes, what type of storage system is used?
  5. Is a life support system being used in your home?
  6. Is a kidney dialysis system used in your home?
  7. Is anyone in your home hearing impaired?
  8. If yes, is your home equipped with a TDD?
  9. Leave This Blank:

  10. This field is not part of the form submission.