REGISTRATION for One Call System for Emergency Contact of People with Special Health Care Needs

The Butler County Health Department is continuing to develop a registry of individuals with medical needs who may require special assistance in the event of a disaster such as a tornado, severe storm, chemical spill or earthquake. These individuals will be contacted utilizing the One Call System, an automated telephone service, which allows the health department to send out a phone message to everyone on the registry at one time when emergency situations are developing or have occurred.

Examples of Special Healthcare Needs are individuals:

  • With severe respiratory problems (oxygen or ventilator dependent) that require a power source or ambu bag
  • Dependent on airway suctioning (tracheotomy)
  • On IV (intravenous) therapy
  • Require tube feedings
  • Require wound care or help with injections on a daily basis
  • With physical or mental conditions that require daily medication
  • Language or cultural barrier
  • Hearing or Speech Impairment

This is a voluntary registration. The information you provide will be confidential and will be used by emergency personnel only to determine our community’s needs in the event of a disaster. In an emergency event you may be contacted via telephone, by an in-office staff or automated message, or by text message.

Items with a * next to them are required to be filled in.

Date of Birth:
City / State / Zip:*
Land-line phone #:
Cell phone #:

Emergency Contact Person:*
Primary phone:* This is a cell phone
Secondary phone: This is a cell phone.

Do you live in:
ApartmentHouseMobile Home

Are you homebound?* YesNo
(If “Yes,” please explain: )

Do you have any medical equipment that requires power:* YesNo

Medical Needs: (Please check all that apply)
Life SupportFeeding TubeInsulin (Self)Insulin (With Assistance)DialysisIV FluidsOxygenSuction UnitVentilatorPortable Oxygen TankConcentrator (For Oxygen)Wheelchair or Walker
  Other Medical Equipment:
Do you currently take medications for (Please check all that apply)
SeizuresRespiratory (Inhalers)Cardiac (Heart or Blood Pressure)Psychological / EmotionalDiabetes (High Blood Sugar)
  Other Medicines:

Is an agency visiting your home currently? YesNo
(If “Yes,” please explain: )

Phone number of Agency:
How long have you been with an In-Home Agency:

The Butler County Health Department utilizes the One Call System. This is an automated system that allows the health department to send out a message via phone to everyone on the registry at one time during emergency situations. This will allow us to reach you faster if you are in need of immediate attention.

Can we add your name/number to our One Call Now automated calling system?* YesNo