| Name | |
|---|---|
| Date | |
| Assessor |
| Risk Factor | Yes | No | Comments |
|---|---|---|---|
| Limited mobility or requires assistance to evacuate | |||
| Relies on medical devices or equipment that require electricity | |||
| Requires life-sustaining medication or treatments | |||
| Has communication, sensory, or cognitive challenges | |||
| No support network available nearby | |||
| Lives in flood, fire, or other high-risk hazard zone | |||
| Other risk factors |
| Emergency Contact Details | |
|---|---|
| Evacuation Plan in Place | |
| Medical Supplies/Medications Accessible | |
| Backup Power/Alternative Communication | |
| Other Key Information |