---

ELECTRIC DEPENDENT: Yes   No   If Yes, check ALL that Apply
Apnea Monitor   BPAP   CPAP   Respirator   Cardiac Monitor   Feeding Pump/Tube  
Nebulizer   Suction Pump   Ventilator   Medication requiring refrigeration   IV Pump
Communication Device

OXYGEN DEPENDANT: Yes   No     If Yes, check ALL that apply.
24 Hour Use   Overnight   Intermittent Number of hours per day   Concentrator
Portable Tank   Mode of Administration: NasalCannula   Face Mask   Liquid   Cylinder
Liters flow/minute  (max 4L/minute)   Oxygen Provider   Telephone

COGNITIVE/DEVELOPMENTAL DISORDER: Yes   No   If Yes, check ALL that apply.
Anxiety   Aphasia   Autism   Conduct Disorder   Depression   Obsessive Compulsive
Seizures   Controlled   Uncontrolled   Requires caregiver to accompany to shelter*
Alzheimer's/Dementia (All levels) Requires caregiver to accompany to shelter
Psychosis   Controlled   Uncontrolled Requires caregiver to accompany to shelter*
Other psychological/developmental disorder
Needs associated with disorder
Disorder Triggers

SPECIAL CARE: Yes   No     If Yes, check all that apply.
Assistance with administering medication   Assistance activities (bathing, dressing, feeding, or other)

Requires constant nursing care   Catheter   Contagious Disease   Currently under Hospice Care
Incontinenece   Bladder   Bowel   Menses
Wound/Rash/Open wound requiring care or dressing changes
Dialysis   Number of times per week   Home   Peritoneal   Facility

OTHER HEALTH CONCERNS Yes   No     If Yes, check all that apply
COPD   Cardiac   Stable   Unstable   Frail/Elderly   ALS   Cancer
Parkinson's   Diabetic   Insulin Dependent   Non-Insulin   Fluid Restrictions
Deaf/Hearing Loss   Hearing Aids
Other assistive Device
Other

Special Diet: Yes   No   If Yes, please explain.

Allergies: Yes   No   If Yes, please explain.

Medications   Please list

Do you have a Medical Power of Attorney? Yes   No

Primary Care Provider

Home Health Care Agency/Supported or Assisted Living/Nursing Home/Other

The Are you Okay Program is a way for those who are homebound, physically incapacitated, or otherwise unable to be in regular contact with someone to help in the event of an emergency. The program requires participants to sign up and provide basic personal information and a signed liability waiver to be added to the Sheriff's Office subscriber list. Once a resident is added to the list, a telephone call will be made to them at their requested interval such as once a day, twice a week, etc. If there is no answer after several tries, then a Point of Contact will be requested to check on the subscriber. If there is no Point of Contact available, then a Law Enforcement Officer will be sent to check on the subscriber.

In the event I do not answer the Are You Okay? Call on the date(s) and the time I indicated above, I authorize the Cochise County Sheriff's Office to send a law enforcement officer to check on my well-being. I further authorize the listed people on pages 1 and 2 to be contact, to check on my welfare or offer further assistance.

Please provide the following additional information for the Are You Okay? System.

Additional Details:

If the registered person has a tendency to wander, please describe places he/she have been found recently or may choose to go:

Medical or psychological concerns relevant to sheriff attempting to assist the registered person to remain safe and stay or leave home:

Items the registered person wears/possesses on a regular basis (such as medical devices, personal items or objects):

Suggestions for ways the sheriffs' deputy can approach and help the registered person:

Regular behaviors and/or special interests:

Medications the registered person MUST take to avoid a medical emergency:

The information contained herein is true and correct to the best of my knowledge. I understand that if accepted, assistance will be provided only for the duration of the emergency, and that alternative arrangements should be made in advance in case I am unable to return to my home.
I understand that based on this application and the data I have provided, Cochise Health and Social Services along with the Cochise Office of Emergency Services will determine which sheltering and emergency evacuation assistance, if any, this program may be able to provide.
I hearby voluntarily and knowingly agree to release and hold harmless Cochise County, Cochise Health and Social Services, Cochise County Office Emergency Services and/or any other Public Safety Organization who responds to assist against any claim in relation to services received through the Are You Okay? Program and At-Risk/Susceptible Population Database.
I understand that this registration is volutary and hereby request registration in the Cochise County At-Risk/Susceptible Individual Shelter and Evacuation Transportation Assistance Program.
By signing this form I give my authorization for medical information contained herein to be released to the Cochise Health and Social Services, Cochise Office of Emergency Services, Canyon Vista Medical Center, Copper Queen Community Hospital, Benson Hospital, Northern Cochise Community Hospital, Southern Arizaona Health Care Coalition and its partners, other medical providers and facilities, fire, emergency medical service and police departments for the purpose of evaluating my needs and providing transportation and sheltering. I understand that this application will expire annually on December 31st and require re-validation prior to March 31st or I will be removed from the program. I further understand that if Cochise County requests updated information or cannot contact me due to changes in my information that may remove me from the registry.

Completed applications can be mailed or faxed to:
Cochise Health & Social Services
Attn: At-Risk/Susceptible Individual Registry
1415 Melody Lane Bisbee, AZ 85603
Fax: (520) 432-9479