Florissant Fire Rescue Home Oxygen Emergency Power Outage Program

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* 1. Does someone in your home use supplemental oxygen?

Yes

No

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* 2. How many people in your home use supplemental oxygen?

1

2

3+

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* 3. Does your oxygen use utilize a concentrator or compressed oxygen bottle?

Oxygen Concentrator

Compressed Oxygen Bottle

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* 4. If you use an oxygen concentrator does your home have a backup generator?

Yes

No

Not Applicable

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* 5. If you do not have a backup generator do you have compressed oxygen bottles as a backup for power loss?

Yes

No

Not Applicable

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* 6. If you used compressed oxygen bottles do you have spare bottles at home?

Yes

No

Not Applicable

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* 7. How many spare bottles do you have at home?

1

2

3+

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* 8. How many liters per minute do you use (household total)?

1-5 Lpm

6-10 Lpm

11-15 Lpm

16+

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* 9. Are you willing to participate in Florissant Fire's emergency power outage home oxygen program?

Yes

No

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* 10. Please provide the information below to be part of our home oxygen emergency power outage program

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number