EMERGENCY INFORMATION – CONFIDENTIAL EVACUATING EARL TOWNSHIP RESIDENTS IN NEED Instructions:  Completely fill out the form, sign the form and then return the form to:                         Earl Township                         Emergency Management                         517 N. Railroad Ave                         New Holland, Pa 17557 Date of Initial Completion: ___________________________ House:  0  Home    0    Rent      0      MH/R Group Home       0    CYA Foster Home Do you SPEAK English?   0    Yes    0    No           Do you READ English?   0    Yes     0    No If the answer is NO, what is your Native Language? _____________________________________________ Personal Information Name: _____________________________________________  Phone: ________________________ Address: ___________________________________________  Cell Phone:  ____________________                             ______________________________ Zip Code____________   Email: _________________________ Date of Birth: ________________________       0    Male        0      Female Mobility:  Check if the answer is ‘yes”   0   Confined to Bed   0   Confined to Wheelchair   0   Require Medical Support Equipment, Oxygen/Ventilator, or Other: _________________________   0   Walk with Walker, Cane or Other: ___________________________________________________   0   Hearing Impaired - Do you have a TTY or similar device   yes      no   0   Sight Impaired   0   Other Personal Situation;  ___________________________________________________________   0   Without any Personal Means of Transportation   0   Service Animal I might not be able to evacuate without help due to a : Mental Disability, Mental Retardation, Autism, Alzheimer’s or due to not being able to verbally respond.   0    Yes      0    No Page 1 This is where I would hide if I was fearful (Inside, Outside): __________________________________ ___________________________________________________________________________________ I must take medicine daily which is prescribed by my doctor:    0   Yes      0   No Primary Care Physician:                                              Telephone Number: __________________________ Name:  ______________________________                 Address: ___________________________________ EMERGENCY CONTACT                                                EMERGENCY CONTACT Name: _________________________________       Name: _____________________________________ Phone: _________________________________      Phone:  ____________________________________ Cell:  __________________________________       Cell:  ______________________________________ Address:  _______________________________      Address:  ___________________________________ _______________________________________      ____________________________________________ E-mail:  ________________________________       E-mail: ______________________________________ Relationship: ____________________________      Relationship: _________________________________ Do you have pets in the household needing evacuation?      0    Yes        0     No EMERGENCY INFORMATION ---- CONFIDENTIAL Privacy Information:  Privacy of Health Information/HIPAA Dsiclosures in Emergency Situations Question:  May an emergency official make disclosures to public officials who are responding to any man-made or natural emergency? Response:  Yes.  Various agencies and public officials will need protected health information to deal effectively with a man-made or natural emergency. To facilitate the communications that is essential to a quick and effective response to such events, HIPAA permits covered entities to disclose needed information to public officials in a variety of ways.  Covered entities may disclose protected health information, without the individual’s authorization, to a public health authority acting as authorized by law in response to a man-made or natural emergency, see 45 CFR 164.512(b), (see 45 CFR 164.512(j), (see 45 CFR 164.512(f); 45 CFR 164.512(k)(2); or judicial and administrative proceedings (see 45 CFR 164.512(e))   Page 2 EMERGENCY INFORMATION  ---   CONFIDENTIAL MY CONSENT My Signature Below Authorizes Earl Township to Share the Information Provided by Me in the Attached Emergency Information Form with:                 •  Lancaster County Emergency Management                 •  Earl Township Emergency Management                 •  Fire Department                 •  Police Department                 •  Earl Township Municipal Officials                 •  Emergency Responders                 •  Emergency Officials My Signature Below Also Represents my Agreement with the Following Statements: Liability:  Neither the County of Lancaster, Pa. (or any of its elected officials, employees, agencies or departments), Earl Township, Lancaster County, Pa. (or any of its elected officials, employees, agencies or departments), nor any of the individuals or entities involved in the accumulation of data, entry of data or use of the data can be assured of the accuracy, completeness, or reliability of the information provided by me or assure the use of that information in an emergency situation.  Under no circumstances shall the County of Lancaster, Earl Township (or any of their elected officials, employees, agencies or departments), or any of the other entities mentioned above, be liable to me, for any claims arising from the use of said information, and I release and discharge the same from any and all claims, demands, suits, causes of action, damages, costs and other legal or equitable remedies arising from the use or possession of said information. Information:   I agree that you may retain my information and use it for emergency planning and response, effective from the date of my signature and continuing until / if I submit a signed, dated notice to the Earl Township Municipal Office, to the attention of Emergency Management, requesting that they remove my information.  I understand that Earl Township may contact me to verify my information, and if I fail to respond, Earl Township may remove my name and information from their data base.  I understand that I am also responsible for notifying Earl Township if I change my address. X _________________________________                 X________________________________     (Signature of Authorized Person)                                                         (Witness) X _________________________________                 X________________________________                           Date                                                                              Relationship Return Your Form To:  Earl Township 517 N. RailraodAvenue New Holland, Pa 17557 Page 3