Date Created: 1/7/2026
2026 State of Texas Emergency Assistance Registry(STEAR)
Local Jurisdiction:
Organization Collecting Information:
Organization Contact Telephone:
Format: (000) 000-0000.
Organization Contact E-mail:
example@example.com
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 each registrant
**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.
Basic Registrant Information - Required information marked with red *
1. * Primary Language. If you speak more than one language, choose the best language thatyou would use for emergency communications. For persons who cannot communicatevocally, please enter non-verbal.
*
English
Spanish
Vietnamese
Hindi
German
Korean
Chinese
Non-verbal
Other
If selected Chinese, please include dialect:
2. * Do you need a sign language interpreter?
*
Yes
No
3. * Are you re-registering because you received a postcard?
*
Yes
No
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Registrant Name:
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Date Created: 1/7/2026
Personal Information
4. * First Name:
*
4a. * Last Name:
*
5. * Physical Street Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
Check this box if the mailing address is the same.
Mailing Street Address (if different from physical address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
7. E-mail Address (if you have one):
example@example.com
8. * Best phone number to reach you:
*
Format: (000) 000-0000.
9. Do you have a second telephone number in case we cannot reach you at the previous number?
Format: (000) 000-0000.
10. Date of Birth
-
Month
-
Day
Year
Date
11. *Age Group
*
0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
91+
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 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.
Emergency contact Name:
First Name
Last Name
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Registrant Name:
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Emergency Contact Information Cont.
12c. What is this person's relationship to you?
Spouse
Parent
Grandparent
Sister/Brother
Child
Grandchild
Aunt/Uncle
Guardian
Other
12d. Emergency contact telephone number. Remember, this needs to be the best way to contact this person in case of an emergency:
Format: (000) 000-0000.
12e. Emergency contact phone type:
Home
Office
Cell
Facility
Caregivers and Animals
13.* If you had to evacuate your home, would you be accompanied by a service animal?
*
Yes
No
14.* Do you have a caregiver, advocate or legal guardian? This person may or may not be the same person who is your emergency contact.
*
Yes
No
15. * How many people do you expect to accompany you when you evacuate? Include your caregiver or legal guardian if evacuating with you:
*
16.* If you had to evacuate your home, would you take a pet with you?
*
Yes
No
16a. [If answered Yes to Q16] How many total pets would need to evacuate with you?
16b. [If answered Yes to Q16a] Do you have carriers for all of your pets?
Yes
No
Emergency Warnings and Instructions
17.* 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?
*
Yes
No
17a. [If answered Yes to Q17] Would you need help reading information because you are blind or have low vision?
Yes
No
17b. [If answered Yes to Q17a] Do you have any other communication needs?
Yes
No
If"Yes", please describe here:
Transportation Assistance
18.* 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.
*
Yes
No
19.* Do you need physical assistance because of a disability to evacuate your home?
*
Yes
No
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Registrant Name:
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Date Created: 1/7/2026
Medically Fragile
20.* Do you identify as a medically fragile individual? If "Yes", proceed to answer questions 21-25a. If "No", proceed to question 26.
*
Yes
No
21. Have you been diagnosed with Alzheimer's or other related disorders?
Yes
No
22. Have you been diagnosed with a debilitating chronic illness?
Yes
No
23. Do you receive dialysis services?
Yes
No
24. Do you have a medical condition that requires 24-hour supervision from a skilled nurse?
Yes
No
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)
Yes
No
25a. [If answered Yes to Q25a] How many hours of power are provided by your back-up power source?
Functional Needs
26.* Do you have a disability or access and functional need that will require additional assistance during an emergency? If "Yes", proceed to answer questions 27-31a. If "No", proceed to question 32.
*
Yes
No
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?
Yes
No
28. If you were away from home, would you need help carrying out activities of daily living, such as bathing, eating, walking, or toileting? Your answer helps to improve plans made for shelters.
Yes
No
28a. [If answered Yes to Q28] Are these services currently provided by someone other than family or friends?
Yes
No
28b. [If answered Yes to Q28a] Please record the service provider and their contact information: Service Provider *:
*
Contact Information *:
*
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Registrant Name:
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Date Created: 1/7/2026
29. Do you have a disability or medical need that will require you to lie down while traveling?
Yes
No
30. Do you weigh more than 350 lbs.? Emergency transport requires special equipment in certain cases if this weight is exceeded.
Yes
No
Functional Needs (cont.)
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.
Wheelchair
Cane
Walker
Nebulizer
Crutches
None
Other
31a. Do you have a motorized or custom wheelchair? Please answer "Yes" if you have a scooter or power wheelchair.
Yes
No
32.* Do you have a storm cellar or safe room in your residence?
*
Yes
No
33. Are there any additional comments or notes that we should enter into your record?
Yes
No
34. How would you like to receive re-enrollment reminders in the future?
Text
Phone Call
Postcard
Email
This form can be filled electronically using Adobe Reader or Adobe Acrobat. When filled electronically, click the button below to send.
If you have trouble sending form electronically, Complete form and save to desktop as a uniquely named PDF file. (Example name: StearIndividualForm_uniquename_date.pdf) Then attach PDF to an email and send to STEAR@tdem.texas.gov.
*Please fill out and submit a new form if any of the information above changes.
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