Johnston County Emergency Services Special Medical Needs Registry

Thank you for taking the Special Medical Needs survey. This survey is designed to identify the locations and needs of the citizens with special medical needs. This information will be used in the event of an environmental emergency like a hurricane, tornado or ice storm. 

A person with special medical needs is defined as an individual with health needs that requires daily medical attention and would be adversely affected by the interruption of services such as utilities, transportation, or daily professional care. 

Our goal is to assist in the preparation process whereby persons can remain at home in a healthy, safe environment. 

If you do not have any major medical concerns that require daily medical attention you should not complete this survey. Additional information about emergency preparedness can be accessed at https://www.johnstonnc.gov/emerserv/em/.


By clicking the SUBMIT button at the bottom of this page, the applicant agrees to their name being added to the Johnston County Emergency Services Special Medical Needs Registry. In the event of an emergency, I hereby authorize the exchange of information between emergency response agencies involved in response to an event or disaster and grant emergency responders permission to enter my home, if necessary, to assure my safety and welfare. 

If you have any questions please call 919-989-5050.
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Patient's Last Name *
Patient's First Name (Legal) *
Patient's Middle Name
Patient's Date of Birth *
MM
/
DD
/
YYYY
Patient's Address *
Patient's Phone Number *
Patient's Primary Language *
If the patient's primary language is other, will an interpreter be present with the patient? *
Name of Emergency Contact *
Emergency Contact Phone Number *
Medical History *
Required
How well is the patient prepared with non-perishable food in the event of a disaster? *
None
Well Prepared
How well is the patient's access to clean drinking water during a disaster?  *
No Access
Well Prepared
In the event of a disaster, will the patient have an adequate supply of personal hygiene products? *
Will the patient have adequate medication and proper storage? *
Will the patient have any medications that will need to be refrigerated? *
Does the patient's home have means of heating and cooling during and after a disaster if power is lost? *
Does the patient have means of communication e.g. cellphone? *
In the event of a disaster, the patient plans to: *
Please indicate the animals you will bring with you to the shelter and the number of each: *
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