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State of Texas Emergency Assistance Registry (STEAR)
Local Jurisdiction: ___________________________________________________________________
Organization Collecting Information: ____________________________________________________
Organization Contact Telephone: ________________________________ Ext: ___________________
Organization Contact E-mail: ___________________________________________________________
STEAR Individual Registration Form
Not for use by assisted living facilities or nursing homes
One (1) form should be completed for each registrant
Please understand that t
he Emergency Assistance Registry assists emergency officials in planning for
emergency events. Having your information helps to determine what kinds of services might be
required during a disaster, and helps responders plan and train more effectively. Communities use
the information in different ways, so realize that having your information in the registry DOES NOT
guarantee that you will receive a specific service during an emergency. Registration is not a substitute
for developing and maintaining your own family disaster plan.
We would like to gather some basic information from you. Sharing this information is completely
optional. To be registered, some basic information is required. You may choose to answer all or only
some of the optional questions. If filling out a paper form, please write the registrant’s name in the
designated space at the bottom of every page of the form.
Basic Registrant Information
Required information marked with *
1. What is y
our primary language? * Spanish Vietnamese English Hindi
Chinese _________________ (dialect) Korean Other ______________________
2. Do you need a sign language interpreter? * Yes No Declined
3. What is your first name? * ______________________________________________________
4. What is your last name? * _______________________________________________________
5. What is your street address? *
Apt/Suite # _____________________________________________________________ _____
6. What is your ZIP code? * ________________________
State of Texas Emergency Assistance Registry Page 1 of 5 Revision Date: 5/14/2013
Registrant Name: _____________________________________________
City of La Porte
La Porte Office of Emergency Management
Required information marked with *
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Basic Registrant Information
7. What is your city?* ____________________________________________________________
8. If known, what is the county you live in? ___________________________________________
9. Are you registering a minor or are you younger than 18? If yes, what is the minor's age? ____
10. What is the best phone number to reach you? * ext. ______________________ ___________
11. Do you have a second telephone number in case you can’t be reached at the previous
number? ______________________ ext.___________
Emergency Contact
In this document, emergencies are defined as hazards to public health and safety, such as hurricanes,
tornadoes, terrorist attacks, chemical accidents, and other disasters that may cause death, injury, or
damage, which could require evacuation and sheltering of the public.
12. We need to gather some information about the best person for emergency planners to
contact in case of an emergency.
What is your emergency contact person’s first name? ________________________________
13. What is your emergency contact person’s last name? ________________________________
14. What is this person’s relationship to you?
Wife/Husband Parent Daughter/Son Aunt/Uncle
Guardian Friend Other _ Declined
15. What is your emergency contact’s telephone number? Remember, this needs to be the best
way to contact this person in case of an emergency. _____________________ ext._________
Caregivers / Animals
16. If you had to evacuate your home, would you be accompanied by a service animal?
No Declined Yes
State of Texas Emergency Assistance Registry Page 2 of 5 Revision Date: 5/14/2013
Registrant Name: _____________________________________________
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Caregivers / Animals
17. Do you have a caregiver or advocate? This person may or may not be the same person who is
your emergency contact. Yes No Declined
18. [If Yes to Q17] During an emergency would your caregiver or advocate evacuate with you?
Yes_ No__ Declined _
19. How many people do you expect to accompany you when you evacuate? _______________
20. If you had to evacuate your home, would you take a pet with you?
Yes No Declined
21. [If Yes to Q20] How many total pets would need to evacuate with you?
22. [If Yes to Q20] Do you have carriers for all of your pets?
Yes__ No__ Declined
Transportation Assistance
23. Will you need transportation assistance in order to evacuate your home?
Yes No Declined
24. Are you able to receive emergency warnings or instructions?
Declined [If No to Q24 proceed with Q25-Q26.] NoYes
[If No to Q24] Would you need help reading information because you are blind or have low
Yes__ No__ Declined
[If No to Q24] Do you have any other communication needs? If yes, please describe here:
State of Texas Emergency Assistance Registry Page 3 of 5 Revision Date: 5/14/2013
Registrant Name: _____________________________________________
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Transportation Assistance
27. Do you have a disability, functional or medical need that may require you to rely on additional
assistance during an emergency? Yes No
If yes, proceed to answer Functional Needs questions. If no, please go to the comments
section [Q39] on the last page of the form.
Functional Needs
Please answer the following questions about the type of assistance you may need during an
emergency. Some of the questions ask for specific health information, but remember, you are not
required to answer these questions if you do not want to.
28. Do yo
u receive medical treatment from a nurse or doctor at your home or in a doctor's office
more than 3 times a week? Yes No Declined
29. If you were away from home, would you need help carrying out daily activities, such as
bathing, eating, walking, or going to the bathroom? Yes No Declined
30. [If yes to Q29] Are these services currently provided by someone other than family or
friends? If yes, please record the service provider and their contact information as a comment
in Q39 on page 5. Yes_ Declined_ No__
31. Are you on portable oxygen? Yes No Declined
32. Do you need assistance leaving your home due to limited mobility?
Yes No Declined
33. Do you have a disability that prevents you from riding in an upright position for up to 4 hours?
Yes No Declined
34. Do you have a life sustaining medical device that requires power?
Yes No Declined
35. [If yes to Q34] How many hours of power are provided by your back-up power source?
hours (up to 72 hours)__________
36. Do you weigh more than 350 pounds? Yes No Declined
State of Texas Emergency Assistance Registry Page 4 of 5 Revision Date: 5/14/2013
Registrant Name: _____________________________________________
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Functional Needs
37. What durable medical equipment, such as a wheelchair, cane, or walker, do you need to have
evacuated with you in an emergency?
Wheelchair Cane Nebulizer Crutches Walker
Other _ ___________________________________________________________________
38. [If wheelchair is noted in Q37] Do you have a motorized or custom wheelchair?
Yes__ No__ Declined
Final Comments
39. Are there any additional comments or notes that we should enter into your record?
40. Are there other people in your home who would need assistance during an emergency? Do
you want to register them as well? Yes No Declined
Fax completed paper form to (866) 557-1074 or, preferably,
Email completed electronic form to STEAR@dps.texas.gov
This form can be filled electronically using Adobe Reader or Adobe Acrobat.
When filled electronically, save the form as a uniquely named PDF file.
Example name: StearIndividualForm_uniquename_date.pdf
State of Texas Emergency Assistance Registry Page 5 of 5
Revision Date: 5/14/2013
Registrant Name: _____________________________________________