Author: gerkK
Last saved by: Lewis Kraus
Company: City of Richmond

2016/2017 NEEDS ASSESSMENT SURVEY OF RICHMOND PERSONS WITH DISABILITIES OR ACCESS AND FUNCATIONAL NEEDS 

Please help us help you by answering the seven questions to improve plans and response capabilities to better serve our community in the future.
 
1.	Are you a person with a disability or access/functional needs?	Yes ___ No  ___

2.	Can you share with us the type of disability or functional need that you have that 
	may need to know to better help you (please check all that apply)?	
		Blind						Developmentally Disabled	
	Deaf, hard-of-hearing			Elderly/Senior
	Medically dependent			Non-English Speaking
	Oxygen Dependent			Physically/mobility challenged	 
	Other (please explain)

4.	In your home now do you have any needs that you would like to share and possibly work with your CERT Neighborhood Team/Richmond Fire OES on?  (i.e.:  need resources or plans on transportation, communications, Meals on Wheels, safety, securing furniture, fire safety, utility shut off, smoke alarms, etc.)

5.	If you had to evacuate your home right now and stay in a temporary shelter for 7-10 days what do you think would be your greatest concerns or challenges?  (Please check all that apply).
 Vital medications	 Medical assistance	 Security/safety 
 Personal Assistant	 Family 			 Transportation
 Mobility Issues		 Service animal		 Special dietary issues	
 Power for recharging essential equipment		 Refrigeration (vital meds)
 Other (Please explain)

6.	Do you have a family/friend support communication plan?  Yes ____ No  ____

7.	Is there anything else that we can do to assist you in to become better prepared? 

Please feel free to use the back of this page.
Name (Optional):  				
Email or physical address:  

Richmond Fire Department Office of Emergency Services,
440 Civic Center Plaza, Richmond, CA.  94804	      Phone: (510) 620-6866 Fax: (510) 307-8048
Thank you