Emergency Contact & Home Hazard Information Form

Emergency Contact & Home Hazard Information Form
Purpose: Please complete this form to assist emergency responders in safely accessing and identifying key information about your property.

(All information will be kept confidential and used solely for emergency response purposes.)
PROPERTYINFORMATION
Address
Name
Contact Number
OCCUPANTS AT LOCATION
Adults (number):
Children (number):
Pets (number and type):
PROPERTY ACCESS INFORMATION
Is there a gate to access your property?
If yes, gate code:
Do you have a spare key accessible to emergency responders?
If yes, location of key:
Is there someone with a key who can be contacted in case of emergency?
If yes, please list:
Name
Phone:
Format: (000) 000-0000.
Relationship
Name
Phone:
Format: (000) 000-0000.
Relationship
Name
Phone:
Format: (000) 000-0000.
Relationship
Do you have a keypad entry or lockbox?
If yes, please give the access code:
SPECIAL NOTES AND SAFETY INFORMATION
Medical considerations (optional):
(e.g., mobility issues, oxygen use, allergies, medicalequipment, etc.)
Do you or any occupants use medical oxygen cylinders?
Are there any occupants with mental health or cognitive conditions emergency responders should be aware of?
If yes, please explain (optional):
STRUCTURE & ACCESS DETAILS
Does your residence have sprinklers?
Does your residence have a basement or a below-grade portion?
If yes, please specify
Does your property have any entrance issues that could inhibit first responders? (Examples: dirt or gravel driveway, weight-limited bridge, long driveway, house far from the street)
If yes, please specify
Does your residence have an elevator?
Does your residence have a hidden/safe room?
If yes, please specify
Does your residence have multiple attic spaces or entrances?
ENERGY & UTILITIES
Is your residence supplied with natural gas or propane (Do you pay a gas bill for your residence)?
Does your residence have a solar panel system?
Does your residence have a backup/standby generator?
Do you have an electric vehicle (EV)?
Is your residence equipped with an EV charging station?
Is your residence equipped with metal roll-down storm shutters?
SAFETY & HAZARDOUS MATERIALS
Does your residence have a swimming pool?
Are there any weapons stored in your residence?
Do you have ammunition reloading supplies?
Do you store any potentially hazardous materials? (Examples: bulk chlorine tablets, welding equipment, large quantities of fuel or chemicals)
If yes, please specify:
Is there anything else you would like us to know about your residence?
SIGNATURE AND UPDATES
Signature
Date

MonthDayYear
Date
Should be Empty:

Emergency Contact & Home Hazard Information Form

PROPERTYINFORMATION

OCCUPANTS AT LOCATION

PROPERTY ACCESS INFORMATION

SPECIAL NOTES AND SAFETY INFORMATION

STRUCTURE & ACCESS DETAILS

ENERGY & UTILITIES

SAFETY & HAZARDOUS MATERIALS

SIGNATURE AND UPDATES