EACH YEAR THE NORTH SMITHFIELD EMERGENCY MANAGEMENT AGENCY CONDUCTS A
SURVEY TO MAKE SURE THAT EVERYONE WILL GET THE HELP THEY NEED IN AN
EMERGENCY.
THE SURVEY HAS THREE PURPOSES
1. FIND OUT WHO IS UNABLE TO HEAR, READ OR UNDERSTAND EMERGENCY MESSAGES
2. FIND OUT WHO NEEDS HELP IF THEY HAVE TO LEAVE THEIR HOME IN AN
EMERGENCY
3. UPDATE ANY INFORMATION YOU MAY HAVE PROVIDED BEFORE
NOTE: EVEN IF YOU RETURNED A SURVEY FORM LAST YEAR, PLEASE TAKE TIME TO
COMPLETE THIS NEW FORM
IF YOU HAVE QUESTIONS ABOUT THIS FORM OR IF YOU NEED HELP , PLEASE CALL
THE NORTH SMITHFIELD EMERGENCY MANAGEMENT AGENCY AT THE TELEPHONE
NUMBER LISTED BELOW
NORTH SMITHFIELD EMERGENCY AGENCY
805 POUND HILL ROAD
NORTH SMITHFIELD, RHODE ISLAND 02896
401-767-2206/ FAX 401-767-02208
STEP#1 Carefully review the items below. Place a check mark(X) in
the box beside those items which apply to you or someone living in your
home. Please mark ALL boxes that apply to any person who
lives in your home. All information is kept confidential!!!
Cannot HEAR (Deaf) (Has TTD/TTY available at this phone
number______________________.
Cannot SEE(seeing eye dog or walking
stick)__________________________________________.
Need an ambulance or medical care to leave home in an
emergency______________________.
Need special vehicle to leave home in emergency(cannot ride in an
automobile or bus) Please describe
problem_________________________________________________________.
Need a ride (transportation is not avialble or cannot ride with a
friend or neighbor during an emergency). How many persons need a
ride_________________?????
Other Help needed( please tell us what type of help
here_____________________________________________________________________________________.
STEP#2 If you did not check any of the above items (STOP) now and
keep this form for future use. If you did check oone or more itemsd, GO
to step#3.
Step #3 ZIf you did check any items showing that you or someone
in your household needs help during an emergency, please fill out the
following.
*********PLEASE PRINT********
Name(s)_______________________________________________________________________________________________________
(of person(s) needing help
Telephone No.______________________________________
Cellphone___________________________
(of person neeeding help)
Name______________________________________________________Telephone
No.___________________________
(of person completing the
form)
(if different from above)
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EMERGENCY NEEDS SURVEY