Assistance Request Survey

Arizona Public Service Company has established “Operation Outreach” as a means of educating and informing residents about nuclear power in general and the Palo Verde Nuclear Generating Station specifically. They are working closely with federal, state, and county emergency management agencies to provide for your health and safety. Maricopa County Department of Emergency Management uses this form in their planning and requests that you complete this informational form whether assistance is needed or not. To get more information you can contact the Maricopa County Department of Emergency Management at (602)273-1411/AZ Relay Service 711 or (602)244-1409 (TTY).

NAME(S) OF PERSONS LIVING IN HOUSEHOLD
First NameLast NameAgeAssistance
Needed?
 
 
   

(additional persons)


Residential Address
Street
Number
Street
Direction
Street
Name
Street
Suffix (e.g. Street, Avenue, Lane, etc.)
Suite / Apt #
City State Zip



Telephone Number(s): Residence: Cell:
Yes
No

Would you, or any member of your family, (including children or elderly home unattended during the day), require additional assistance to leave your home on short notice? Please check ALL that apply that best describe any disability or medical condition that affects your mobility.
Please note any other assistance you would require.
Yes
No

Please Check ALL that apply that best describe any disability or medical conditions.
Yes
No

Do you have a telephone? Telephone No.:
Yes
No

Will you need transportation during an emergency?
Yes
No

Do you have pets? (If so, how many and what type?)

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