Personal Disaster Plan
Consumer Name:
First Name
Last Name
Consumer Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consumer Phone Number:
Please enter a valid phone number.
Emergency Contact:
First Name
Last Name
Emergency Contact Phone Number:
Please enter a valid phone number.
Providing Agency Name:
Supported Living Coach:
First Name
Last Name
SLC Phone Number:
Please enter a valid phone number.
Copies of Disaster Plan to be provided to:
Consumer
Support Coordinator
Supported Living Coach
Persona Supports Worker
PLAN A: My Personal Plan to Shelter in Place:
My first choice will always be to shelter in my own home unless County Emergency Management mandates evacuation, or the emergency situation makes me feel that I may not be safe if I remain in my home.
I have the following Supplies:
3-day supply of water ( 1 Gallon/day for each person in my home; water replaced every 6 months)
3-day supply of nonperishable food that requires little/no cooking and little/nowater to prepare.
Battery-operated radio and extra batteries.
Flashlight for each person in the home and extra batteries.
First aid kit with bandages, cleansing agent, antiseptic, gloves, sunscreen, overthe-counter meds, etc.
Sanitary supplies including toilet paper, hand sanitizer, bleach, personal hygieneitems, garbage bags.
Duct tape, precut plastic sheeting to cover ducts and all openings in interior roomdesignated for shelter in event of a chemical or biological threat.
Other tools/supplies: disposable cups, plates and utensils; multipurpose utility tool;hand held can-opener; whistle; matches/lighter; rain gear; complete change of clean dry clothing; bedding/sleeping bag; charged cell phone and charger; cash; pet supplies; games, books, entertainment supplies.
I maintain at least a 3-day supply of my prescription medication at all times, in the event of a potential disaster.
I have a waterproof container that has copies of my identification, emergency contact information, insurance papers, list/proof of valuables; evacuation communicator, disaster plan, updated medical and prescription information, bank and credit card information, Social Security information and other important documents.
The supports who helped me to ensure that all the above has been completed, all equipment is in working order, and that all personal information is current on a quarterly basis is:
Please Select
Guardian
SLC
Coordinatior
Personal Support Worker
I require the following special dietary supplies, durable medical equipment and/or consumable medical supplies:
Special Dietary Supplies
Durable Medical Equipment
Consumable Medical Supplies
Type of required Supplies (oxygen, feeding tube):
If I need assistance as I shelter in my home, this person(s) will remain with me in my home:
First Name
Last Name
Phone number of individual staying with you in your home.
Please enter a valid phone number.
Plan B: My Personal Plan When I Must Evacuate:
If I must evacuate my home during an emergency or disaster, I am prepared to follow this plan:
I have the following:
Go Kit (I have an easy-to-carry "Go Kit" prepared that contains or can be readily packed to contain the following supplies that I have reserved in my home and will take with me to the shelter: at least a 7-day supply of meds; Items required for special diet; a 3-day supply of water and non-perishable food and snacks; personal hygiene essentials; first aid kit; battery-operated radio and extra batteries; flashlight and extra batteries; cash; cell phone and charger; bedding/sleeping bag; at least one complete change of clean dry clothing; glasses; hearing aids; durable and consumable medical supplies; waterproof container that has copies of all of my important documents; multipurpose utility tool; whistle; matches/lighter; rain gear; games, books, entertainment supplies.
(I have a plan for my pet(s). My pet will either go to the designated pet shelter in my county or I have arranged for this person/veterinarian to take care of my pet(s) for me
I will Evacuate to one of these locations if I can evacuate within the area:
First Choice:
Name, Address & Phone Number
Second Choice: If circumstances prevent me from evacuating to my first choice, I will evacuate to:
Name, Address & Phone Number
I have transportation arranged to get to both my first and second choices for both of my in-area and out-of-area evacuation destinations.
Please Select
Yes
No
If Yes, who has committed to assisting you in evacuating?
Name & Phone Number
If you need assistance when you evacuate, who will remain with you for the duration of evacuation?
Name & Phone Number
Plan C: My Personal Plan if I must Go to a Shelter or Medical facility:
I understand that shelters operated by County Emergency Management and the Health Department are available but should only be used as a last resort and as a back-up to My Personal Sheltering Plans A and B. Note: Shelters may be crowded, noisy, lack privacy and may be especially challenging for persons with behavioral health needs. However, if circumstances make it necessary for me to go to a shelter or medical facility; this is my plan:
I have determined what type of shelter or medical facility that I will need to go to:
General Population Shelter (I will be able to go to a general population shelter because I do not need the type of care and supervision that is provided in a special needs shelter)
Special Needs Shelter (I will need to go to a special needs shelter because I need electricity for life supporting medical equipment, or basic nursing care, or oxygen therapy, or observation/monitoring by a healthcare professional, or assistance with medication andno one to assist me, or a chronic condition that requires assistance from a healthcare professional, or special medical requirements that do not require hospitalization or another special need that cannot be accommodated in a general population shelter. My condition may warrant a caregiver to go with me to a Special Needs Shelter to care for me while I shelter there)
Medical Facility (I will need to go to a medical facility because my special medical requirements exceed what can be provided in a special needs shelter)
If Applicable, general population Shelter
Name & Location
If Applicable, Special Needs Shelter
Name & Location
If Applicable, Medical Facility
Name & Location
This person helped me determine where I need to go:
First Name
Last Name
Transportation: I have identified how I will get to my designated shelter
I will need to use transportation arranged and provided by County Emergency Management and have confirmed this with them.
I will be transported by this person/company
Person or agency providing transportation:
Name & phone Number
My Personal Commitment Disaster Preparedness:
I understand the following:
I understand that I have a personal responsibility for disaster preparedness and I am committed to working in a proactive manner with County Emergency Management andthe people who support me to follow my Personal Plan for Disaster Preparedness.
I have received training and information from this person about my personal responsibility for preparing for all types of disasters including hurricanes, tornadoes, wildfires, earthquakes, floods, chemical and biological spills/ attacks, nuclear power accidents, terrorist attacks, etc.
Consumer Signature:
Supports Signature
Signature Date:
-
Month
-
Day
Year
Date
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