JJ Johnston

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					                                    PASCO COUNTY, FLORIDA
                                                  "Bringing Opportunities Home"

                 Dade City                            (352) 521-5137              Office of Emergency Management
                 Land O'Lakes                         (813) 996-2411                Emergency Operations Center
                 New Port Richey                      (727) 847-8137                        7530 Little Road
                 Facsimile                            (727) 847-8004               New Port Richey, FL 34654-5598

Dear SNAPP Client:

Although you are currently registered with the Pasco County Special Needs and Assistance Population Program
(SNAPP) for notification, transportation or sheltering assistance in case of an emergency evacuation, the
Legislature of the State of Florida enacted new laws governing the program. There are several impacts of the
new law which you need to be aware of and the impact on your care. Your Emergency Management agency is
required to gather updated information concerning your physical and mental needs. Enclosed is a new
application for registration in the program. Please fill out the form in entirety and return within 30 days of
receipt of this letter to ensure that our records are updated for the 2010 Hurricane Season. All information
contained within our files needs to be as accurate as possible and will be kept confidential.
Your signature is extremely important, as it acknowledges registration acceptance, certifies that the information
is correct, and acknowledges the following program guidelines. Assistance will be provided only for the
duration of the emergency. Alternative arrangements must be made in advance, in case you are not able
to return to your home. Registration does not guarantee assignment to a Special Needs Unit. Clients will be
screened based on the information provided to determine if assignment to a Special Needs Unit is appropriate
and necessary. Clients with complex medical conditions exceeding the capabilities of a Special Needs Unit
are advised that hospitals and nursing homes require that your physician pre-arrange for temporary
admission. Pasco County does not have admission privileges at medical facilities. Any costs arising from
hospital or other medical facility care or medical transportation is your responsibility. Pasco County complies
with the Health Insurance Portability Act of 1996 (HIPAA). As such, your signature grants permission to
medical providers and transportation agencies and others as necessary to provide care and disclose any
information necessary to respond to your needs. You are granting permission for the release of this information
to emergency response agencies and pre-authorizing these agencies to enter your residence for the purpose of
emergency search and rescue. You are acknowledging that registration in this program is voluntary.
There are limitations to the services the County may provide to assist individuals in an emergency.
Special Needs Units have a limited number of cots. There are no hospital beds or prescription medications. If
you are currently receiving home health care or oxygen/respiratory services your provider is required to
continue service delivery in the special needs unit or wherever you have planned to shelter, as long as
there is access to the area. Pets, other than certified assistance animals, are not allowed in shelters. If you
have a pet, you must pre-plan with friends, veterinarians, or boarding kennels to care for your animal. A Special
Needs Unit provides limited medical monitoring and services. These limitations are set out for you in the
accompanying Client Information Sheet. Should you have any questions or require any additional information
concerning this matter, please call (727) 847-8137.


James Johnston
Operations Coordinator

"Pasco County—Florida's premier county for balanced economic growth, environmental sustainability, and first-class services."
                     CLIENT INFORMATION

All residents are strongly encouraged to pre-plan to evacuate the area when necessary.
 Your best and safest evacuation choices include staying with relatives or friends out of
the evacuation area, checking into a hotel/motel, or pre-admission into a medical
facility. Where you can best be supported during a hurricane should be a joint
decision of your physician, home health agency, caregiver, family and yourself. To
assist in making a decision concerning your care, this overview of the program and the
limitations is provided for you.
Because we realize a portion of the population does not have the option of independent
evacuation out of the area, the American Red Cross operates public shelters. Public shelters
are NOT a hospital, nursing home or hotel. The shelter is generally a local school. Public
shelters available under emergency conditions will accept anyone who is self-sufficient, and
needs no outside professional assistance in performing Activities of Daily Living (ADL).
The Pasco County Public Health Department manages Special Needs Units within some
American Red Cross public shelters. Special Needs Units are available for those
individuals who require assistance with Activities of Daily Living (ADL). Basic medical
assistance and monitoring will be available. Special Needs Units are NOT equipped with
advanced medical equipment or medications, or staffed to provide advanced medical care.
If you need 24 hour skilled nursing care, a hospital bed or are electric dependent for
life support, you are NOT a good candidate for Special Needs Units. All residents who
are oxygen dependent MUST bring extra tanks, nebulizers, meds, and any other
necessary equipment. Dialysis clients MUST dialyze immediately prior to departing
for the Special Needs Unit. CPAP units which are not “life sustaining” will not be
supported in the shelter.
Florida Statute REQUIRES home health agencies/nurse registries/hospice/oxygen and
durable medical equipment suppliers to provide continuing care to their clients
whether in a special needs unit or with friends or family, weather and access
permitting. All residents presenting to a special needs unit MUST be accompanied by
their caregiver.

If your physician has decided that you need to be cared for in a skilled nursing facility, such
as a hospital or nursing home during an emergency, he/she MUST arrange pre-admittance
prior to evacuation with a specific facility. You MUST have a copy of the pre-admission
letter from your Doctor stating that you are to be taken to a specific (in-County) hospital or
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nursing home and arrangements have been made with the facility for admittance. This letter
MUST accompany you when you are evacuated. Medicare will only pay claims that are
deemed medically necessary and therefore arrangements MUST be made in advance. If
any costs arise from your admittance, you are responsible for those costs. Medical
facilities will not accept patients without a physician’s orders.

Residents who require transportation will be taken to public shelters, Special Needs Units,
or medical facilities. Transportation is NOT provided to private homes, hotels, etc.
Transportation is NOT provided outside of the County.

Share your plans with a relative/friend outside the area. Call them after a disaster and let
them know that you are all right. Make a plan for alternate living arrangements in case you
can not return to your home due to damage. When a hurricane or other emergency is
threatening Pasco County, continually monitor radio and/or TV to determine if you are
included in the evacuation area. If your area is ordered to evacuate, gather your belongings
and proceed to your evacuation destination. If you have registered for transportation, units
will be dispatched to your location. If time allows, you will receive a confirming
telephone call.
Pack a Hurricane Survival Kit with the following items, and take it with you when you
      medications (2 week supply)
      medical support equipment (wheelchairs, walkers, dressings, oxygen, feeding
       equipment, diapers, nebulizers, neb meds, etc.)
      name & phone number of your doctor, home health agency, hospital, next of kin
      ID & valuable papers
      food for special dietary needs
      personal hygiene items/clothing change
      lawn chair or cot, blanket or sleeping bag, and a flashlight
      pillow
      sweater
      book, cards, or game to pass the time
      cash for purchases after a disaster

You are responsible to make arrangements in advance for your pets to shelter with
friends, veterinarians, or boarding kennels. Pets are NOT permitted in public shelters.
The only exception to this rule is a certified assistance animal.

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Fasano Regional Shelter
11611 Denton Avenue
Hudson, FL

Traveling SR 54 or SR 52 to Little Road: Proceed north to Denton Avenue
and turn right. Continue approximately 2.5 miles to the shelter (on left side,
yellow building).
From North of Denton Avenue: Take Little Road south to Denton Avenue.
Turn left, and continue approximately 2.5 miles to the shelter (on left side,
yellow building).

Wiregrass High School
2909 Mansfield Blvd
Wesley Chapel, FL

From the West: Take SR 56 over the I75 overpass to Bruce B. Downs Blvd,
turn right onto Bruce B . Downs to County Line Road, turn left onto County
Line Road to Mansfield Blvd, turn left and follow Mansfield Blvd to the
school. Upon entering the school grounds, go to the farthest building to
From the East: take SR 54 to Meadow Point Blvd, turn left onto Meadow
Point Blvd, go to Beardsley Drive, turn right onto Beardsley Drive, proceed
to Mansfield Blvd, turn right and follow Mansfield Blvd to the school. Upon
entering the school grounds, go to the farthest building to unload.
                                                                                                                               PASCO COUNTY
                                                                                                                Special Needs Assistance Population Program (SNAPP)
                                                                                                                  EVACUATION REGISTRATION REQUEST FORM
                                                                                                                          (PLEASE PRINT CLEARLY)
                                                                  Last Name:                                                              First Name:                                              MI:

                                                                  Date of Birth:               Height:          Weight:                                                               # of Pets:   Type of Pets:
                                                                                                                             Do you live alone?                       Yes No
                                                                                                                             Do you live in a Mobile Home?            Yes No
                                                                  Telephone:                                    TDD:     Primary Language:
                                                                                                                Yes No
                                                                                                                                                             Will someone be accompanying you to the
                                                                                                                                                             shelter?                Yes No
                                                                  Street Address:                                            City:                                        Zip Code:                Lot/Apt#:
Failure to complete the entire form WILL delay your evaluation!

                                                                  Subdivision/Mobile Home Park Name:
                                                                  Mailing Address (if different than living address):                     City:                                       Zip Code:

                                                                                                  PLEASE PROVIDE US WITH THESE IMPORTANT PHONE NUMBERS
                                                                                                                     NAME                            TELEPHONE#
                                                                  Home Health Agency
                                                                  Oxygen Provider
                                                                  Medical Supplier
                                                                  Physician's Hospital
                                                                  Dialysis Center
                                                                  Attendant's Name
                                                                      Does your attendant have a medical condition? Yes No
                                                                      If yes, please list his/her conditions:
                                                                  Next of Kin
                                                                   WHAT IS YOUR DISABILITY?                                                    DO YOU USE ANY SPECIAL EQUIPMENT?
                                                                          (Please check ALL that apply)                      (Please check ALL that apply)

                                                                  1                                                          1
                                                                                 I have NO disabilities.                                  I do NOT use any special equipment.
                                                                  2                                                          2
                                                                                 I am blind.                                              I use suction equipment.
                                                                  3                                                          3
                                                                                 I am hearing impaired.                                   I use a feeding pump.
                                                                  4                                                          4
                                                                                 I am in a wheelchair.                                    I use a nebulizer.
                                                                  5                                                          5
                                                                                 I am bedridden                                           I use a concentrator.
                                                                  6                                                          6
                                                                                 Other:                                                   I require oxygen : HRS/DAY ________ LITRE FLOW ________
                                                                                 _______________________                                  I use a ventilator.
                                                                                 _______________________                                  I use IV equipment.
                                                                                 _______________________                                  I am electric dependent. Why? ____________________

                                                                                               WHAT ARE YOUR MEDICAL CONDITIONS? (Please check ALL that apply)
                                                                  ____ Heart Problems (HP)                      ____ Central Venous Line (CL)                ____ Immune Suppressed (IS)
                                                                  ____ Blood Pressure (BP)                      ____ DNR Orders (DN)                         ____ Cancer (CA) Type: __________________
                                                                  ____ Stroke (ST)                              ____ Tracheotomy (TR)
                                                                  ____ Diabetes (DB)                            ____ Incontinence (IN)                       ____ Dialysis (DI)       # of times weekly: ______
                                                                  ____ Breathing Problems (BR)                  ____ Alzheimer's (AZ)
                                                                  ____ Back Problems (BK)                       ____ Autism (AU)                             Other:       ____________________________
                                                                  ____ Seizures/Convulsions (SC)                ____ Depression (DP)                                      ____________________________
                                                                  ____ Contagious Disease (CD)                  ____ ADHD/OCD (BH)                                        ____________________________

                                                                                                                                                             PLEASE TURN PAGE OVER TO CONTINUE

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                                                                                                                             PASCO COUNTY
                                                                                                              Special Needs Assistance Population Program (SNAPP)
                                                                                                                EVACUATION REGISTRATION REQUEST FORM
                                                                                                                        (PLEASE PRINT CLEARLY)
                                                                                             "I TAKE THESE TYPES OF MEDICATIONS…." (Please check ALL that apply)

                                                                                                              Self administered and shelf kept
                                                                                                              Intravenous, self administered, and shelf kept
                                                                                                              Intravenous, self administered, and refrigeration is required
Failure to complete the entire form WILL delay your evaluation!

                                                                                                              Non-self administered medications
                                                                                                              I DO NOT take any medications

                                                                             PLEASE BRING A CURRENT LIST OF ALL YOUR MEDICATIONS WITH YOU WHEN YOU EVACUATE

                                                                                      PLEASE TELL US ABOUT YOUR TRANSPORTATION NEEDS (Please check only ONE)

                                                                                                              I will provide my own transportation to the shelter.
                                                                                                              I normally ride the bus.
                                                                                                              I am confined to a wheelchair
                                                                                                              I am totally bedridden.
                                                                                                              I have a hearing/seeing eye animal accompanying me
                                                                       If your condition is deemed extremely "fragile" by your physician and it therefore recommended that you take
                                                                     shelter at a hospital or nursing home instead of a public Special Needs Shelter, a copy of your physician's orders
                                                                                      to be pre-admitted to a pre-designated facility MUST accompany this application.
                                                                                               The original must be on your person at the time of transportation.

                                                                      The information contained herein is true and correct to the best of my knowledge. I have read the Special Needs Assistance Population Program
                                                                  Applicant Information Sheet accompanying this request and I understand that limitations on the services and level of care available. I understand that
                                                                  this registration is voluntary and hereby request registration in the Pasco County Special Needs Assistance Population Program.

                                                                      I understand, based on the information I have provided, that I may or may not be assigned to a special needs unit based on the criteria stated in the
                                                                  information provided. I understand that I am responsible for providing any prescription medications, oxygen supplies, medical equipment, and special
                                                                  dietary items that I may require during the emergency. If my physician determines that I need a higher level of care than can be provided in a Special
                                                                  Needs Unit and arrangements will be made to pre-admit me to a medical facility; I also understand that I will be responsible for any charges and costs
                                                                  associated with hospital or other medical facility care or medical transportation.

                                                                    I understand that assistance will be provided only for the duration of the emergency, and that alternative arrangements should be made in advance in
                                                                  case I am not able to return to my home. I grant permission to medical providers and transportation agencies and others as necessary to provide care
                                                                  and disclose any information necessary to respond to my needs. I hereby grant permission for the release of this information to emergency response
                                                                  agencies and pre-authorize these agencies to enter my residence for the purpose of emergency search and rescue.

                                                                  SIGNATURE:                                                                                                DATE:

                                                                  REPRESENTATIVE (If you are unable to sign):

                                                                  RELATIONSHIP TO THE APPLICANT:

                                                                                                                                Return form to:
                                                                                                               PASCO COUNTY Office of Emergency Management
                                                                                                                 7530 Little Road, New Port Richey, FL 34654
                                                                                                                              or FAX TO (727) 847-8004.

                                                                                                                      For more information call (727) 847-8137

                                                                                                                  **********FOR OFFICIAL USE ONLY**********

                                                                   ________      ________        ________       ________      ________        ________         ________       ________      ________
                                                                     SEC          TSHIP           RANGE          LEVEL        SHELTER           SNU               T             COFL          AMB

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