City of Los Fresnos

Department of Emergency Management

Special Needs Data Sheet

     The Los Fresnos Department of Emergency Management is trying to obtain from our Citizens, the number of people that would need assistance evacuating in the event of a natural disaster.  The City wants to assure it’s Citizens that we will assist anyone that is in need, when there is know one else they can call upon.  But, to make sure resources are not stretched to a beyond it’s limits, we strongly suggest that our Citizens “if able” make arrangements with family members for assistance during an evacuation.  This form is to be filled out if the Citizen has no other means of assistance.  Below is a description on medical needs levels, by knowing how many people that are in a household and their level on medical need.  It will help us be better prepared in the event that we assist you during an evacuation.  Please read the levels carefully, and place the number of members in your household on the levels that they meet.  Please return this form with your child or bring it to the Los Fresnos Police Department located at 200 N. Brazil St. Los Fresnos TX. 78566.  This from is also available on the City’s Website (www.cityoflosfresnos.com).  Once at the website click on Emergency Management.  The form will be located at the top of the page under the title of SPECIAL NEEDS DATA SHEET. 

Types of Medical Special Needs

LEVEL-0: Persons, who have no medical needs, but require transportation assistance for evacuation.

LEVEL-1: Persons dependent on others or in need of others for routine care (eating, walking, toileting, etc.) and children under 18 without adult supervision.

LEVEL-2: Persons with physical or developmental disabilities such as blindness, significant hearing impairment, amputation, deaf/blind, and mental retardation.

LEVEL-3: Persons requiring assistance with medical care administration, monitoring by nurse, dependent on equipment (including dialysis), assistance with medications, and   

                 mental health disorders.

LEVEL-4: Persons outside an institutional facility care setting who require extensive medical oversight (i.e. IV chemotherapy, ventilator, life support equipment, hospital bed and

                 total care, morbidly obese)

Head of Household Contact Information

Name:   Address:

Age:      Sex:   M F     Home Phone:  

Nearest Relative Contact Information

Name:     Address:    

Relation:   Phone: