Seconds Matter, Keep Your First-Responders Informed.
Share critical information with local FIRE, POLICE and EMS to better prepare for an emergency at your home or business.
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What should your First-Responders know in case of an emergency at your home?

About This Survey:
To better protect you, your loved ones, and your property, the Pound Ridge Volunteer Fire Department, Pound Ridge Lions Volunteer Ambulance Corps, and the Pound Ridge Police Department request your help by completing the Emergency Pre-Plan Survey below. The objective is to collect important information to better prepare your local First-Responders in the event of an emergency at your home or business. The information we are gathering focuses on residents with special needs, medical conditions, pets, challenging driveways, building construction, utilities, hazards, and more. Knowing these things before an emergency can make all the difference. Submitted information will be reviewed by First-Responders and actionable information will be incorporated into local emergency pre-plans.

Time:
5 minutes to complete.

Participating Agencies:
Pound Ridge Volunteer Fire Department
Pound Ridge Lions Volunteer Ambulance Corps
Pound Ridge Police Department
 
I am completing this survey for... *

The following survey will only be used by Pound Ridge Fire, Police, and EMS.

 
Last name of Resident(s)? *

 
If street name is not list, please enter it here.

 
House Number? *

 
Do you own or rent this property?


 
Best phone number to contact this address?

There is a space for emergency keyholders later in the survey.
 
Occupancy, Medical Conditions, and Pets

 
Would any occupants require special assistance in an emergency?

e.g. Senior citizens, difficulty moving, medical conditions, autism, disabilities, etc...
     
 
If a resident may require special assistance in an emergency, can you please share more information about their situation?

Please include:
Name
Condition
Contact Information
Year of Birth

e.g. “John Smith is an elderly male, difficulty walking under own power, typically uses a walker. Born 1940.”

 
Do any occupants rely on oxygen therapy or medical devices?

e.g. Home oxygen supply, ventilators, dialysis, etc.
     
 
If a resident relies on oxygen therapy or a medical device, can you please share more information about their situation?

In addition to oxygen, at home devices may include Suction units, Ventilators, Dialysis, Left Ventricular Assistance Devices (LVAD), etc. Please include:
Name
Condition

Contact Information
Year of Birth
e.g. "80 year old male on required oxygen therapy."
 
Do you have any pets living in the house?

     
 
How many Dogs do you have?

 
How many Cats do you have?

 
If other, describe which type of indoor pet(s) lives here?

(Please exclude fish. If none, leave blank)
 
Driveway and Property Info

When seconds matter, it's crucial First-Responders can quickly access your driveway and find the emergency.
 
How long is your Driveway?





 
Do any of the following apply to your driveway or property?

If any of these apply, please elaborate on the next page.

 
Please describe anything about your driveway that will help First-Responders unfamiliar with your property.

During an emergency, seconds matter. Please share anything that may help us in locating and best accessing your property.

e.g. “Split driveway, left is #7 and right is #8.”

e.g. “Rear of property is accessible from our neighbor's driveway at 8 Richmond Lane.”

e.g. "Secondary dirt access road with a gate that leads to rear of property. 300 feet right of the driveway."
 
Home Construction

Knowledge of your home's construction can help firefighters more effectively fight fire.
 
Was your house built prior to 1950?

Fire Stops: Pre-war houses typically do not have fire stops in the walls between floors. Fire stops are a building technique using either wood, dry-wall or a combination of materials to slow fire from running up wall voids. If you know your house lacks fire stops in between floors, select Yes. 

(If unsure, leave blank)
     
 
Are there additional structures and/or residences on your property?

e.g. Guest cottage, barn, apartments, detached garage
     
 
If there is an addtional structure on your property, can you please describe what it is used for and where it is.

e.g. "Detached garage with an apartment."
e.g. "Barn towards the rear of the property is now used as a gym and office space"
 
Select all that are true about your basement:


 
How is your attic accessed?


 
Utilities

Last section! Can you tell us more about the utilites that power your house?
 
Do you have an automatic standby home generator?

Note: Only select "Yes" if this is a non-portable standby home generator preconnected to the residence.
     
 
Can you tell us where your generator is located and where the emergency shut-off is?

e.g. "Generator is located on left side of garage, emergency shut-off located on unit."
 
Please select the primary heating method for your home:


 
Are there large permanent propane tanks on your propety?


 
If there are large above ground propane tanks on your property, can you tell us their location and capacity?

e.g. "1,000 gallon tank above ground concealed in the bushes on the left side of our property"
 
Are there any other hazardous materials or chemicals located on the premises?

Please ignore small amounts of fuel for lawn mowers, household cleaning products, and paint.
     
 
If there are unique hazardous materials or chemicals, please describe them and their locations in detail.

Please ignore small amounts of fuel for lawn mowers, household cleaning products, and paint.
 
Can you concisely describe where your home’s circuit breaker panel(s) are located and if you have more than one?

e.g. “Middle of the wall, farthest from garage/basement staircase.”
e.g. “Breaker is hidden in basement closet at the bottom of the stairs.”
e.g. “Located in back utility room of our finished basement. This room is 20 feet from the stairs.”
 
List all emergency key holders and their cell phone numbers.

e.g. Jon Snow (914) 555-5555
(Please only list individuals who live nearby and who can help first-responders gain access)
 
Last question! 

Is there any other pertinent information you would like to share in case we're called to your home for an emergency?

There are no dumb answers!
 
Legal Disclaimer *

Attention: Data Chief, LLC is a middle entity organizing this survey on behalf of the Pound Ridge Fire Department, Pound Ridge Lions Ambulance Corps and the Pound Ridge Police Department for the purpose of obtaining information helpful to first-responders during emergencies in Pound Ridge. We do not want you to submit any information you may deem sensitive or important to the overall security of your Premises. No information submitted is protected under the Health Insurance Portability and Accountability Act (HIPPA). We do not guarantee that all submitted information with be incorporated into emergency pre-plans or that it will be used during an emergency. To edit or remove submitted information, please email requests to Support@datachief.info. Submitted information will NOT be resold by Data Chief, LLC or by any of the participating Emergency Services. I, the Submitter of this survey, do hereby agree to the terms and conditions listed above.
     
Thank you! Your information will be reviewed by First-Responders. If you'd like to complete this survey again for another address, click the blue button below.

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