MERCER COUNTY SHERIFF'S CENTRAL DISPATCH
E-911 SURVEY
NAME: _______________________________________________TELEPHONE NO.:_____________________________
MAILING ADDRESS:__________________________________________________________________________________
DIRECTIONS TO RESIDENCE: __________________________________________________________________________
_____________________________________________________________________________________________________
INDICATE TYPE OF DWELLING: ________ ONE STORY
________ TWO STORY
______ APARTMENT ______ MOBILE HOME ______ WITH BASEMENT
OTHER UNATTACHED OUT BUILDINGS: (Describe)__________________________________________________________
_____________________________________________________________________________________________________
RESIDENTS: Please list all occupants including spouse, children, all individuals with disabilities or handicaps and other family or non-family members who may reside in your home. Include prescription medications or other medical information, which may provide important information to emergency medical personnel. ALL information is voluntary and if provided will be kept confidential and used only in the event of an emergency.
NAME
|
DATE
OF BIRTH |
SEX |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Mail to: Mercer
County Sheriff’s Office 911
125
W. Livingston St. - Celina, OH 45822