Critical Care Life Support Form | Cape Hatteras Electric Cooperative

Name

Service Address

Village

Phone Number

Type of Life Support Equipment

Other necessary Equipment (lights, pumps, etc)

Is the equipment used continuously?

Yes

If not used continuously, how many hours/days is it used?

Can the equipment be use hand operated?

Yes

Do you have back-up generation to run this equipment?

Yes

Emergency Contact

Emergency Contact Phone Number