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Date
Physical Address of Shelter
City
State
Zip
Owner/Resident (Last Name, First Name)
Phone Number
Additional Phone Number
Occupancy Use ResidentialCommercialIndustrialOther Use of property
Type of Shelter BasementSafe Room (above ground)Safe Room (below ground)Cellar (outside of the house)Cellar (under the house)Closet/Bathroom Select the type of shelter listed above. Even if no shelter, location in house when taking shelter.
Adults Inside 123 or more Number of adult occupants inside shelter
Children Inside None123 or more Number of children occupants inside shelter
Pets Inside None123 or more Number of pets inside shelter
Emergency Supplies 1 day or less2 to 5 daysOne week or moreNo supplies
Location of Shelter Garage (in floor)Garage (safe room)CellarClosetBedroomBackyardFront YardSide Yard
Special Medical Needs/Comments Fill out field with any special medical needs like oxygen, high blood pressure, heart patient, etc.
Year of Construction Approximate year safe room was installed/constructed. If cellar, date not needed.
Rent House YesNo
