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Palo Verde Generating Stations Annual Survey

  1. Residential address

    You can also find this survey form on-line at Click on the Palo Verde Generating Station link and then the Evacuation Assistance link. If you have questions or would like assistance to complete this survey please contact (602) 273-1411 or TDD/TTY (602) 244-1409

  2. Names of Household Members

  3. Assistance Needed

  4. y
  5. n
  6. y
  7. n
  8. y
  9. y
  10. Text
  11. Text
  12. n*

    Would you or any member of your family, (including children or elderly  home unattended during the day), require evacuation transportation assistance to leave your home on short notice?

  13. Do any household members utilize

    (check all that apply)

  14. Please check ALL that apply that best describe any disability or medical condition
  15. 1. Do you have a food garden that you grow broad-leaf produce (lettuce, spinach, cabbage, etc.) that is at least 500 square feet?

  16. a
  17. 2. Do you have a goat or cow that you gather milk from?

  18. h
  19. 3. Do you have any additional animals/pets? If yes, how many?

  20. h
  21. Leave This Blank:

  22. This field is not part of the form submission.