Fillable Broward County Special Needs Shelter and Evacuation Transportation (Broward County)

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Broward County Special Needs Shelter and Evacuation Transportation (Broward County)

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Broward County – Special Needs Shelter and Evacuation Transportation Assistance Application
Thank you for your interest in the Broward County Adult Special Needs Shelter. Please understand that the
shelter is a place of refuge of last resort from dangerous weather or other emergencies. While basic services
such as food, electricity, and medical supervision will be provided, clients and caregivers must provide
supplemental food and all medications for the first five (5) days. Please remember: Cots are provided for
clients. Cots may not be available for caregivers.
CLIENT CONTACT INFORMATION
LAST NAME: FIRST NAME: MI:
PHYSICAL ADDRESS: Bldg. #: Apt
/Lot #:
DEVELO
PMENT/SUBDIVISION: City:
ZIP:
RESI
DENCE TYP
E: Single Fam
ily Apartment / What floor? Condo / What floor?
Mobile/Manufactured Recreational Vehicle Boat
MAILING ADDRESS (if different than above):
LIVING SITUATION: Alone Relative Other
D.O.B. (Required) / / AGE: Gender: Male Female Other No response
DO YOU EXCEED 450 POUNDS? Yes No
PRIMARY PHONE#: SECONDARY PHONE #: E-MAIL
IS YOUR PRIMARY TELEPHONE TTY/TTD (Teletype): Yes No
WHAT IS YOUR PRIMARY LAN
GUAGE? RACE/ETHNICITY
EMERGENCY CONTACT INFORMATION
1.
NAME: RELATIONSHIP
PRIMARY PHONE# _ SECONDARY PHONE# E-MAIL _
□
CHECKING THIS BOX ALLOW MEDICAL INFORMATION TO BE SHARED WITH THIS INDIVIDUAL
2.
NAME: RELATIONSHIP
PRIMARY PHONE# _ SECONDARY PHONE# E-MAIL _
□
CHECKING THIS BOX ALLOW MEDICAL INFORMATION TO BE SHARED WITH THIS INDIVIDUAL
AT LEAST ONE EMERGENCY CONTACT MUST BE PROVIDED
Last Name:
_
First Name:
Middle Initial
2
Rev. 5/2018 bb
(
EVACUATION TRANSPORTATION ASSISTANCE
Are you registered with TOPS? Yes ( ) No ( ), if yes what is your PIN number?
1. Do you require transportation to a shelter? ( ) YES ( ) NO
2. MOBILITY AID: Please check off ALL that apply to you:
( ) Can walk without help ( ) Cane ( ) Crutches ( ) Walker ( ) Electric Scooter
( ) Manual Wheelchair ( ) Electric Wheelchair
( ) Confined to a bed ( ) Sleep on hospital bed at home ) Use a special lift to get out of bed
3. Do you require help when walking? Yes ( ) No ( )
4. If you use a Wheelchair, do you require help transferring? Yes ( ) No ( )
5. Check the one that applies to you:
a. I cannot get outside my home
b. I can get to the curb outside my home
6. Blind or Vision loss? Yes ( ) No ( )
7. Do you have a service animal? Yes ( ) No ( ) , if yes what kind
8. Are you able to sleep on a portable medical cot (see information below)? ( ) Yes ( ) No
1.
18 inches high (wheelchair height)
2.
32 inches wide X 80 inches long
9. Will anyone be coming with you to the shelter? Yes ( ) No ( )
If Yes, name/relationship:
Total number of persons to be picked up from this address?
Number of persons requiring wheelchair
_
First Name:
Middle Initial
Rev. 5/2018 bb
Last Name:
MEDICAL SUPPORT INFORMATION
PRIMARY DOCTOR:
PHONE:
HOME HEALTH AGENCY:
PHONE:
HOSPICE PROVIDER: PHONE:
HOME MEDICAL EQUIPMENT PROVIDER: PHONE:
DIALYSIS CENTER: PHONE:
OXYGEN SUPPLIER: PHONE:
SPECIAL NEEDS (check all that apply)
Electrical Needs
□
Apnea Monitor
□
Bi-Pap or C-Pap Machine
□
Cardiac (Heart) Monitor
□
Feeding Tube Pump
□
IV Medication: Please specify:
Assistance With
Daily Living
□
Going to the toilet
□
Taking medications
□
Feeding/Eating
Specialized Equipment
□
Feeding Tube
□
Foley Catheter for urine
□
IV Equipment
□
Medication requiring refrigeration
□
Nebulizer
□
Oxygen Dependent:
□
24 hours
□
Overnight
□
Concentrator
□
Portable Tank
□
Liter Flow per Minute
□
Suction Pump
□
Ventilator/Respirator
(A machine that
moves air in and out of your lungs
because you cannot breathe on your
own)
□
Walking more than 50 ft.
□
Getting out of bed
□
Dressing
□
Tracheostomy Tube
□
Other
Last Name:
_
First Name:
Middle Initial
Rev. 5/2018 bb
Psychological Conditions
□
Alzheimer’s/ Dementia
(requires caregiver)
□
Anxiety
□
Autism
□
Conduct Disorder
□
Depression
□
Obsessive Compulsive Disorder
□
Psychosis controlled with medication
□
Psychosis not controlled with medication
□
Other psychiatric diagnosis:
Neurologic/Sensory
□
Blind / Visually Impaired
□
Deaf / Hearing Impaired
□
Difficulty swallowing
foods or liquids
□
Seizures controlled with
medication
□
Seizures not controlled with
medication
Special Care
□
Foley Catheter
□
Open wounds/ bed sores
□
Wound V.A.C.
□
Incontinent
□ Urine □ Stool
□
Ostomy
□
Adult Diapers
□
Tracheostomy
□
Dialysis: # days per week
Hemodialysis ( )
Peritoneal dialysis ( )
□
Special Diet
DIAGNOSIS (Check all that apply)
Chronic but Stable
Illness
□
Aphasia (Difficulty communicating)
□
Asthma □ controlled with medications □ not controlled with medication
□
Heart Disease □ controlled with medication □ not controlled with medication
□
Cancer Please specify:
□
Contagious Disease Please specify:
□
Diabetes/ high blood sugar
□ Insulin Dependent
□
Fractured Bones (Pin care/dressing changes)
□
Hemophilia
□
Infection Please specify:
□
Lung Disease (COPD / Emphysema /Bronchitis)
□
MRSA
□
Neurological Deficit Please specify:
□
Renal (Kidney) Disease
□
Sickle Cell Anemia
□
Skin Rash Please specify:
□
Stroke
Chronic but Stable
Illness
With Mobility
Impairment
□
Cerebral Palsy
□
Frail/elderly
□
Wheelchair Bound due to Chronic Illness (Such as: ALS, Cerebral Vascular
Accident (stroke), Multiple Sclerosis, Muscular Dystrophy, etc.)
Electricity Dependent
□ Electric Medical Equipment
Last Name: _ First Name: Middle Initial
Rev. 5/2018 bb
List any other medical
problems:
Allergies to medications or foods: □ YES or □ NO, If yes, Please specify:
PRESCRIPTION MEDICATION (please attach list if necessary)
Medication Name:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Dose:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
# of times per day:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Last Name: _ First Name:
Middle Initial
Rev. 5/2018 bb
Broward County Special Needs Emergency Shelter and Evacuation
Transportation Assistance Application
STATEMENT OF UNDERSTANDING AND SIGNATURE AUTHORIZATION FOR USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION (PHI)
The information contained herein is true and correct to the best of my knowledge. I understand that if
accepted, assistance will be provided only for the duration of the emergency, and that alternative arrangements should
be made in advance in case I am unable to return to my home.
I understand that based on this application and the data I have provided, Florida Health in Broward County,
along with the Broward County Emergency Management Division, will determine which sheltering and emergency
evacuation assistance, if any, this program may be able to provide.
I understand that this registration is voluntary and hereby request registration in the Broward County Special
Needs Shelter and Evacuation Transportation Assistance Program.
By signing this form I give my authorization for medical information contained herein to be released to the
Broward County Human Services Department, Florida Health in Broward County, Memorial Health Care System, Holy
Cross Hospital, Broward Health, and other hospitals, medical facilities and providers, the Broward County Transit
Division, and the Broward County Emergency Management Division, for the purpose of evaluating my needs and
providing transportation and sheltering. I give authorization for Broward County to resend page 2 of my application to
the physician listed on an annual basis for update. I understand that changes to the information submitted requires
completion of a new application and re-submittal. I further understand that if Broward County requests updated
information or cannot contact me due to changes in my information they may remove me from the registry. This
authorization shall remain in effect for 12 months from the date of signature.
With the exception of e-mail addresses, records relating to registration of persons requiring functional needs support
are exempt from the provisions of F. S. 119.07 (1), Public Records Law. Except as otherwise provided by this
authorization, the information you provide will be kept confidential.
Applicant/Patient Full Legal Name
(PRINT):
Applicant/Patient Signature:
Date:
If this authorization is signed by an individual’s personal representative, or health care provider, on behalf of the individual, please complete the
following:
Personal Representative’s Full Legal Name
(PRINT): Relationship
Contact Information (include telephone #)
Personal Representative’s Signature:
Date:
Completed applications must be mailed to:
Broward Emergency Management Division
Attn: Special Needs Registry
201 NW 84
th
Avenue Plantation, FL 33324
954/831-3902
If you have questions about this authorization, or to revoke this authorization prior to the expiration date or event, you must submit
a written request to the above address.
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Broward County Special Needs Shelter and Evacuation Transportation (Broward County)

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Completed 27 August 2020

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