Texas Department of Aging
and Disability Services
Form 1085
March 2013
State of Texas Emergency Assistance Registry (STEAR)
Contact Information for Data Collector
Organization: Contact Name:
Contact Area Code and Telephone No.
Contact Email:
STEAR Facility Registration Form – For use by assisted living facilities, nursing homes, etc.
One form should be completed for each facility.
1. Name of the facility
2. Street address Apt/Suite No.
3. City
4. ZIP code
5. County
6. Contact area code and telephone
7. Estimated daily average census
8. Do you have an evacuation plan for your facility residents if there is an emergency?.......................................... Yes No
9. Are there any additional comments or notes I should enter into your record?
Fax completed form to 866-557-1074
Forms can be filled electronically using Adobe Reader or
Acrobat and saved as uniquely named PDF files.