HCP4 2025 STEAR FORM
  • Image field 1

  • 2025 State of Texas Emergency Assistance Registry (STEAR)

  • STEAR Individual Registration Form

    Not for use by assisted living facilities or nursing homes. That form can be found at stear.texas.gov One (1) form should be completed for reach registrant. If you are getting assistance filling out this form, please have the person assisting you fill out the following:

  • **By registering in STEAR you are consenting to sharing your information with first responders and other state agencies during a disaster. **

    Please understand that the 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.

    Last-minute enrollments during a disaster event may not immediately reach your local emergency management office. For more information on local participation in STEAR, contact your local office of emergency management.

    We would like to gather some basic information from you. To be registered, some basic information is required. 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.

  • Format: (000) 000-0000.

  • Basic Registrant Information-Required information marked with red*

  • 1. Primary Language. If you speak more than one language, choose the best language that you would use for emergency communications. For other languages or persons who cannot communicate vocally, please enter non-verbal in the other section.*
  • 2. Do you need a sign language interpreter?*
  • 3. Are you re-registering because you received a postcard?*

  •  State of Texas Emergency Assistance

    Registry Individual Registration Form TDEM 25

    Page 1 of 6

  • Basic Registrant Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  •  / /
  • 11. Age Group (years old)*

  • Emergency Contact Information

    In these questions, 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 evacuations and sheltering of the public. We need to gather some information about the best person for emergency planners to contact in case of an emergency below.

  •  State of Texas Emergency Assistance

    Registry Individual Registration Form TDEM 25

    Page 2 of 6

  • 12.c What is this person's relationship to you?
  • Format: (000) 000-0000.
  • 12e. Phone Type

  • Caregivers and Animals

  • 13. If you had to evacuate your home, would you be accompanied by a service animal?*
  • 13a. Do you have a caregiver, advocate or legal guardian? This person may or may not be the same person who is your emergency contact.*
  • 13b. (Answer only, If you answered Yes to Q13a) During an emergency would your caregiver, advocate or legal guardian evacuate with you?
  • 15. If you had to evacuate your home, would you take a pet with you?*
  • 15b. (If you answered Yes to Q15a) Do you have carriers for all your pets?

  • Emergency Warnings and Instructions

  • 16. Do you have a disability or medical condition that would prevent you from receiving or understanding emergency warnings or instructions whether in your home or away from home?*
  • 16a. (Answer only, If you answered Yes to Q16) Would you need help reading information because you are blind or have low vision?
  • 16b. (Answer only, If you answered Yes to Q16) Do you have any other communication needs?

  •  State of Texas Emergency Assistance

    Registry Individual Registration Form TDEM 25

    Page 3 of 6

  • Transportation Assistance

  • 17. Do you have transportation to evacuate? Answer "Yes" if you have a vehicle or someone you know to drive you to an out-of-town location. Answer "No" if you DO NOT have a way to evacuate. Planners use this question to estimate how many people need transportation during an evacuation.*
  • 18. Do you need transportation assistance to get to a local evacuation assembly point or shelter? A "Yes" means you DO NOT have a way to get from your home to a local assembly point.*
  • 19.Do you need physical assistance because of a disability to evacuate your home?*

  • Medically Fragile

  • 20.Do you identify as medically fragile individual? If "Yes", proceed to answer questions 21-25a. If "No", proceed to question 26*
  • 21. Have you been diagnosed with Alzheimer's or other related disorders?
  • 22. Have you been diagnosed with a debilitating chronic illness?
  • 23. Do you receive dialysis services?
  • 24. Do you have a medical condition that requires 24-hour supervision from a skilled nurse?
  • 25. Do you use life sustaining medical devices that requires power? (Examples would include a breathing machine, suction unit, oxygen concentrator, ventilator, or feeding pump).

  •  State of Texas Emergency Assistance

    Registry Individual Registration Form TDEM 25

    Page 4 of 6

  • Functional Needs

  • 26.Do you have a disability or access and functional needs that will require additional assistance during an emergency? If "Yes", proceed to answer questions 27-31. If "No", proceed to question 32.*
  • 27. Do you receive critical medical treatment from a nurse or doctor at your home or in a doctor's office more than 2 times a week?
  • 28. If you were away from home, would you need help carrying out activities of daily living, such as bathing, eating, walking, or toileting? You answer helps to improve plans made for shelters.
  • 28a. (If you answered "Yes" to Q28) Are these services currently provided by someone other than family or friends?

  • 28b. (If answered "Yes to Q28a), Please record the service provider and their contact information here

  • 29. Do you have a disability or medical need that will require you to lie down while traveling?
  • 30. Do you weigh more than 350 lbs.? Emergency transport requires special equipment in certain cases if this weight is exceeded.
  • 31. What durable or bulky medical equipment, such as a wheelchair, cane or walker, do you need to have evacuated with you in an emergency? Please check all that apply. Your answer helps evacuation transportation planners.
  • 31a. (If "Yes" to Wheelchair in Q31), Do you have a motorized or custom wheelchair? Please answer "Yes" if you have a scooter or power wheelchair.
  • 32. Do you have a storm cellar or safe room in your residence?
  • 33. Are there any additional comments or notes that we should enter into your record?
  • 34. How would you like to receive re-enrollment reminders in the future?

  •  State of Texas Emergency Assistance

    Registry Individual Registration Form TDEM 25

    Page 5 of 6

  • 2025 State of Texas Emergency Assistance Registry (STEAR)

  • Section I: HCP4 STEAR Acknowledgement 

    By filling out this form, you consent to allowing Harris County to register you in the STEAR program and to use your personal information for Harris County services. The 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.

    Your participation 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. Last-minute enrollments during a disaster event may not immediately reach your local emergency management office. For more information on local participation in STEAR, contact your local office of emergency management.

    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.

  • 3a. Is this a new application, renewal application, or update of information***

  • Click this Button to Email Completed electronic form to STEAR@tdem.texas.gov

    This form can be filled electronically using Adobe Reader or Adobe Acrobat. When filled electronically, click above button to send. If you have trouble sending form electronically, Complete form and save to desktop as a uniquely named PDF file. (Example name: StearlndividualForm_uniquename_date.pdf Then attach PDF to an email and send to STEAR@tdem.texas.gov.

    Complete form, print, and then fax paper form to (866) 557-1074. *Please fill out and submit a new form if any of the information above changes.

  • Image field 55

  •  State of Texas Emergency Assistance

    Registry Individual Registration Form TDEM 25

    Page 6 of 6

  •  
  • Should be Empty: