Emergency Information Form for People with Special Needs (English and Spanish)

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Emergency Information Form for People with Special Needs (English and Spanish)

Disaster Preparedness
Preparedness Resources
Active response
Pediatric Disaster Care Centers of Excellence (ASPR)

Audience

Patients & Families

Media Type

Infographic

Duration

This form was adapted from the Emergency Information Form for Children with Special Needs. It is intended for individuals of any age with special healthcare needs. This is a bi-lingual form in both English and Spanish. (2009)

Emergency Information Form for People with Special Needs (English and Spanish)

What care setting do you primarily work in?

EMS or fire-rescue agency

Emergency department

Trauma center

Other clinical setting

I do not work in a clinical setting

Which EMS agency or hospital do you currently work for? (May select up to three)

If your agency or hospital is not listed above, please specify

Please make sure you have searched for your agency or department's full, official name above before adding it.

Form version*

Requested resource

User action*

Uuid*

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The EMSC Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $2.74M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS or the U.S. government. For more information, visit HRSA.gov.