SOUTHAMPTON VILLAGE POLICE DEPARTMENT
151 Windmill Lane
Southampton, New York 11968
EMERGENCY PREPAREDNESS INFORMATION
This form is intended to collect
vital information
required to assist Police, Fire, and Ambulance personnel when responding to your home or business in the event of an emergency. Please take the time to complete the entire form before you submit it. When you have finished filling out the form click the submit button located at the bottom of the form. Your emergency responders appreciate your cooperation in performing this invaluable service.
PLEASE REMEBER TO ANSWER ALL QUESTIONS
TYPE OF LOCATION:
Business
Residence
BUSINESS / RESIDENCE NAME:
Street Address:
Telephone #:
Fax #:
PROPERTY OWNERS NAME:
Mailing Address:
Telephone #:
Fax #:
Emergency Contact Person(s):
Who will respond with a key in the event of an emergency? It is highly recommended using someone that can respond within 15 minutes.
Name:
Telephone #:
Name:
Telephone #:
Name:
Telephone #:
Provide your contractors name and telephone number that performs these services:
Alarm Co:
Telephone #:
Electrician:
Telephone #:
Elevator Serv. Co:
Telephone #:
Fire/Sprinkler Co:
Telephone #:
Fuel Oil Co:
Telephone #:
Furnace/Boiler Ser. Co:
Telephone #:
Generator Serv. Co:
Telephone #:
Guard Serv. Co:
Telephone #:
Propane Del. Co:
Telephone #:
BUSINESS RESIDENCE LOCATION INFORMATION:
How long has your business/residence been at its present location?
My Business / Residence is on the
North
South
East
West
– Side of the Street.
Approx.
Feet
North
South
East
West
of (Cross Street)
Other descriptive features about your home/business that would help responders locate it in an emergency:
Nearest fire hydrant location:
Feet
North
South
East
West
of the premise.
Please check all that apply for the above property:
Gated Driveway
Narrow Driveway (< 12ft)
Winding Driveway
Height Restrictive Driveway (< 12ft)
Fire Sprinklers / ANSUL System
Pets Located Inside Premise
Garage Apartments
Property Located on a Flag Lot
Basement Apartment(s)
Metal Hurricane / Riot Doors
Third Floor Living Space
Hazardous Materials Stored Outside
Tempered Hurricane Windows
Barricade Type Bars on Door(s)
Guard Dog on Premise / Property
Anti Theft Window Bars (Ground Floor)
Do you have firearms or reloading supplies on the premise?
Yes
No
If YES please list all in COMMENTS box below.
If applicable - Driveway Gate Code (
For Emergency Responders Only)
Do you have a KNOX Box at your location?
Yes
No
If YES where is it located?
If NO information about Knox Boxes and other Knox Rapid Entry System products can be found at
www.knoxbox.com
.
Are there any occupant(s) with Special Needs that reside or frequent your home or business?
Yes
No
Please check all that apply:
Physical Disability
Hearing Impaired
Vision Impaired
Other
Does an occupant require a wheelchair or walker for mobility?
Yes
No
Does an occupant require oxygen or special life support equipment while at home?
Yes
No
If required to evacuate during an emergency,
will the occupant with special needs require any special equipment, medications, medical personnel or transportation?
Yes
No
If YES please explain the needs and special instructions:
COMMENTS:
Please make sure that you have filled out the above form correctly before submitting it.