ADDRESS___________________________________________________________________________ SNAP#______________________ KENT / SUSSEX COUNTY HOME INFORMATION FORM FOR THE SPECIAL NEEDS ALERT PROGRAM (SNAP) THIS FORM TO BE ATTACHED TO EMERGENCY INFORMATION FORM AND SHARED WITH RESPONSE UNITS Home visits are not available in New Castle County. Use the New Castle County Home Information Form. Child’s Name:_______________________________________ Name child responds to:__________________________________ Date of home visit:___________________________________________________________________________________________ Contact person at visit:____________________________________________ relationship:____________________________ Contact Numbers: home: ____________________________________ work:_____________________________________________ Cell:____________________________ pager:____________________________ other:___________________________________ Caregivers Name(s): ______________________________________ relationship:______________________________________ ______________________________________________________________________________________________________________ ALS agency and representative on home visit:__________________________________________________________________ BLS agency and representative on home visit:__________________________________________________________________ House Address and description-i.e. brown ranch/ where to find house #: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Best entrance for patient:____________________________________________________________________________________ Child’s room location:________________________________________________________________________________________ Primary medical issue:________________________________________________________________________________________ Other medical issues / diagnoses:_____________________________________________________________________________ ______________________________________________________________________________________________________________ High Tech equipment:__________________________________________________________________________________________ ______________________________________________________________________________________________________________ Does this child need to be transported to a specific facility? ___ Y ___ N If yes, which facility?:______________________________________________________________________________________ Other special instructions/issues:____________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health Office of Emergency Medical Services Easter Seals SNAP This project was supported in part by grant number 1 H33 MC00112-03 form the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Doc. #35-05-20/07/03/21 04/09/07